Provider Perspectives‘And then one day he’d shot himself. Then I was really shocked’: General practitioners’ reaction to patient suicide
Introduction
Suicide and suicide attempts are major public health problems worldwide and suicide is a leading cause of death and of years of life lost [1], [2], [3]. Most people who end their life by suicide have a treatable mental disorder [4] and in patients with a known mental disease, up to 91% (n = 224) have consulted their GP during the year before their death, half having their final GP consultation in the month before death and a sixth in the week before death [5]. The overall reported proportion of individuals consulting GPs in the month prior to suicide averaged 45% (20–76%), and on average 77% (57–90%) see their GP in the year before the suicide [6]. Far more patients at risk of suicide contact their GP than the mental health service during the last month before suicide [6], [7]. Suicide ideation has been reported as present in 2.4–6.3% of primary care patients [8], [9]. However, often the suicide ideation is not communicated to the GP [10], [11], or the contact is about seemingly non-psychiatric issues [12]. Patients with mental disorder usually present to their GP with somatic symptoms without directly disclosing the mental problem [13], [14]; there is a low rate of inquiry and detection of suicidal thoughts by primary care practitioners [15]. It has been suggested that fear of accusation of suboptimal clinical expertise may dissuade GPs from enquiring too deeply if they do not believe they have the means to manage the risk [16]. There is, however, no evidence that identifying risk is harmful; on the contrary it has been found to reduce suicides [17]. It has been shown that there is significant physician variance in exploration of suicide ideation. The frequency of exploration is increased by prompts from patients, acknowledged mental disorder or request for antidepressive treatment [2].
As patients have often contacted their GPs, perhaps for other reasons, shortly before a suicide GPs could be expected to often have the memory of patients who have ended their life by suicide. Nevertheless, the emotional effect of patients’ suicides on their GPs has been little studied. Only one study was found. It deals with the affect on rural British GPs, showing that they were less emotionally affected than were psychiatrists [18], who have been shown to be greatly affected by patients’ suicides [19], [20]. A possible explanation could be a greater intensity of the therapeutic relationship between psychiatrist and patient [18].
A study into the effect of patient suicide on consultant psychiatrists demonstrated a substantial personal impact in terms of low mood, sleep disorder or irritability. Some made changes in professional practice; some thought of taking early retirement. The study concluded that support from colleagues is helpful and that opportunities exist for improved management of suicide and its aftermath [21]. The study did not deal with GPs, but a Rapid Response to the study [22] reported an audit among GPs showing that family doctors are in a vulnerable position; 90% (n = 61, response rate 85%) experienced a sense of hopelessness at some point and a significant proportion felt frustration, rejection and guilt. Few felt the suicide was preventable. The GPs in the audit reported they received little outside support.
The present study aimed to investigate how GPs were affected by patients’ suicides and whether their reaction was linked to their propensity to explore suicide risk in the patient who committed suicide, and how the GPs’ current propensity was to explore suicide risk.
In a larger qualitative study about GPs’ process of understanding patients with common mental disorders and their experience of doing psychological interventions [23], [24], [25], participants were asked whether they had experienced patient suicides and if so, how this had affected them. The participants readily talked about this issue and also about their inclination to explore suicide ideation, especially in patients with depression. This article reports a special analysis of the data material concerning the theme patient suicide.
Section snippets
Method
The study was qualitative with data material consisting of semi-structured interviews with 14 GPs in Denmark. This paper is part of a larger study exploring GPs’ process of understanding patients with psychological or emotional problems. The methodological details have been described thoroughly elsewhere [24], [26] but are summarised here.
Emotional impact, guilt and failure
A patient's suicide was an event that became engraved on the GP's mind. All participants except one had experienced one or more suicides among their patients and these suicides were all very fresh in their memories. Without needing time to consider, GPs could recall the number of suicides they had experienced in their practice time, when each suicide was and what the circumstances were.
‘During the time I’ve been here we’ve had three patients who committed suicide. A mother of two small girls,
Discussion
All participants except one had experienced suicide among their patients; this event had deeply affected them all. They had been struck by guilt, a feeling of failure, self-scrutiny and a need to reformulate the situation. An automatic reaction seemed to be the assumption that they had overlooked something. The suicides that had had the greatest impact were those where there had been contact about some undiagnoseable somatic symptoms and the GP had not arrived at a cognition of the suicide
Conclusion
All the GPs were deeply affected by patients’ suicides. They were emotionally shaken and felt guilt, failure and self-scrutiny when a patient committed suicide. The emotional impact was linked to whether they had realized and explored the risk. However, they explored suicide ideation only in patients diagnosed with depression. In particular, they felt failure when they realized that a patient who had presented with vague somatic symptoms had committed suicide and they had not diagnosed a
Practice implications
There is a need for more research to identify GPs’ need for support in this and probably other emotionally stressful situations. Furthermore, the fact that the participants did not explore suicide ideation unless they had diagnosed depression indicates that there could be a need to strengthen GPs’ capacity to identify suicidal risk in patients who do not give any indications but exclusively present with vague bodily symptoms. This would potentially prevent some suicides and in addition increase
Conflict of interest
None.
Acknowledgement
I thank the participants who contributed to this study.
Funding: The research for this paper was supported by funds for research in primary care in the former Aarhus County and in Danish Regions.
References (46)
- et al.
Identifying suicidal ideation among older adults in a general practice setting
Journal of Affective Disorders
(2004) - et al.
Psychosocial problem disclosure by primary care patients
Social Science & Medicine
(1999) - et al.
Preventing suicide in primary care patients: the primary care physician's role
General Hospital Psychiatry
(2004) Experiences of carrying out talking therapy in general practice: a qualitative interview study
Patient Educ Couns
(2008)- et al.
Nondetection of depression by primary-care physicians reconsidered
General Hospital Psychiatry
(1995) - et al.
Screening for suicide risk in adults: a summary of the evidence for the US preventive services task force
Annals of Internal Medicine
(2004) - et al.
Let's not talk about it: suicide inquiry in primary care
Annals of Family Medicine
(2007) - et al.
Prevention of suicide
Psychiatric Annals
(2007) - et al.
Major depression, physical illness, and suicidal ideation in primary care
Psychosomatic Medicine
(2003) - et al.
Primary care contact prior to suicide in individuals with mental illness
British Journal of General Practice
(2009)
Contact with mental health and primary care providers before suicide: a review of the evidence
American Journal of Psychiatry
Suicide and recency of health care contacts. A systematic review
British Journal of Psychiatry
Suicidal ideation in primary care
Journal of General Internal Medicine
Suicide victims’ contacts with physicians during the year before death
European Archives of Psychiatry and Neuroscience
Does every allusion to possible suicide require the same response?
Journal of Family Practice
General practitioner contacts with patients before and after deliberate self harm
British Journal of General Practice
Epidemiology of mental-disorders in primary-care settings
Epidemiologic Reviews
Suicide mitigation
British Journal of General Practice
Addressing hopelessness in people with suicidal ideation: building upon the therapeutic relationship utilizing a cognitive behavioral approach
Journal of Psychiatric and Mental Health Nursing
The impact of patient suicide on rural general practitioners
British Journal of General Practice
The psychiatrists role, responses, and responsibilities when a patient commits suicide
American Journal of Psychiatry
Impact of death by suicide of patients on Thai psychiatrists
Suicide and Life-Threatening Behaviour
Suicide by patients: questionnaire study of its effect on consultant psychiatrists
British Medical Journal
Cited by (21)
A qualitative study on nurses’ reactions to inpatient suicide in a general hospital
2016, International Journal of Nursing SciencesCitation Excerpt :Non-psychiatric patients had less suicide communication or warning, performed suicidal acts more rapidly, used more violent suicidal methods than the psychiatric inpatients did [12]. Therefore, the response of inpatient suicide on practitioners has been understudied [13,14]. But to the best of our knowledge, scant data looked specifically at the effects of inpatient suicide on nurses.
The impact of patient suicide and sudden death on health care professionals
2014, General Hospital PsychiatryCitation Excerpt :It is understandable, whether warranted or not, that some HCPs might report feelings of shock, guilt or shame in such circumstances. These findings replicate previous studies of HCP reactions to suicide [1,2,14]. In their professional practice, some HCPs reported that after the suicide, they had become more vigilant and proactive in suicide risk assessment along with being more assertive in getting specialist or additional mental health input for suicidal patients, while others obtained additional training.
Patient suicide: The experience of Portuguese doctors and psychologists
2013, Revista Portuguesa de Saude PublicaIntegration of suicidology with general medicine: An obligation to society
2011, Patient Education and Counseling