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“Every life is touched by suicide:” Stanford psychiatrist on the importance of prevention

Most people shy away from talking about suicide. Me too – I have some personal ties to the topic that still stab every time the s-word comes up. Yet after the initial reluctance wears off, that pain from grief and anger and fear turns into a motivational jab. Let’s talk about suicide nonstop. Let’s talk to make it stop.

Laura Roberts, MD, who leads Stanford's psychiatry department, had the opportunity as editor-in-chief of the journal Academic Psychiatry to focus attention on suicide prevention. And she took it - partnering with the Wisconsin-based Charles E. Kubly Foundation to produce a special package of articles to inform clinicians about the latest efforts to prevent suicide.

Roberts and I spoke recently about the special issue and about suicide prevention:

Why did you want to publish this issue?

Suicide is such an under-recognized phenomenon, and it is an urgent threat to public health. Mental illness affects one in five people. Each year, more than 36,000 people commit suicide in the U.S. That is one person every fifteen minutes. In rough numbers, that's twice the number of people who die from a violent injury in this country. Really, every life is touched by suicide.

Despite their serious public-health impact and life-threatening nature, illnesses and conditions associated with suicide have received little attention in society. These conditions are poorly understood and so greatly stigmatized. Learning to understand and evaluate people at risk for self-harm is an important element of medical student and resident education — we really wanted to emphasize these topics in this special collection.

New evidence-based models for prevention of suicide are emerging and inspire optimism. Integrating these new models is an exciting challenge for medical educators. Papers in this collection also document the impact of suicide and suicidal behavior among medical students and graduate students. About 350 physicians commit suicide each year in the U.S., and recently two interns in New York City ended their lives shortly after entering residency training. This is devastating.

In our special issue, a systematic review highlights the observation that psychiatry residents commonly experience the death of a patient by suicide, and three articles address coping with suicide professionally. Several articles focus on the development of educational programs that help strengthen suicide prevention, including screening skills and suicide awareness and management. Two articles address the resources and experience of from the Department of Veterans Affairs.

The journal special issue underscores there is much we can do in medical education to foster understanding and strengthen our responses to the phenomenon of suicide. Taken together, the papers also show how important it is that academic leaders better educate other about the prevention and impact of suicide.

What have we learned about preventing suicide?

We have learned a great deal about the prevention of suicide. Population data have shown that certain subgroups are especially vulnerable to suicide, including, for example, older white men who are ill and live alone, Native American youth as they make the transition to adulthood, and people living with serious illnesses that cause great physical and emotional pain. Understanding these larger population patterns has done a lot to help raise awareness of suicide and has allowed for creative interventions to address this problem.

Recently, researchers have been pursuing neurobiological markers that may signal when an individual is most at-risk for attempting suicide. Other studies are connecting other aspects of health — such as healthy sleep and exercise — to protective factors that may help diminish the likelihood of suicide. Such innovative work is very much needed because it will help us understand when a person with latent risk factors for suicide may act on this impulse, or, alternatively, how we can better support and intervene.

Other recent work has focused on psychological and situational factors that may contribute to suicidality among young veterans, and again, this line of inquiry may give us greater understanding on how best to reduce suicide deaths. As you may know, the number of veteran deaths due to suicide have been devastating. The VA has shown immense concern for members of the military and young veterans returning from conflicts around the world. In the course of studying suicide in this population, we have begun to have greater insight into when and whether an individual will act on an impulse to end his life. Three factors appear to be in play: first, a predisposition or vulnerability, for example, the presence of depression or anxiety that increases the general risk of suicide; second, access to a way to end one's life, such as a gun; and, third an experience or set of experiences that make the individual feel like he is out of place, isn't part of things, and doesn't belong — what's referred to as "thwarted belongingness."

We are getting parts of the problem figured out, but so much more scientific investigation is needed. Ironically, suicide has been understudied because of concerns that the population is too vulnerable to be included in human research studies and because of the stigma associated with suicide. There have been so many barriers to these studies, and it strikes me as doubly tragic that suicide takes so many lives and yet has been relatively neglected by society and by science. In the Department of Psychiatry and Behavioral Sciences at Stanford, we are working to turn this around.

How does Stanford train its future psychiatrists to deal with suicide?

From the first week with our psychiatry residents, we are working with them to identify people at risk for suicide, how to approach a vulnerable person in a supportive way. It's part of their training continuously for years.

Physicians in training are a vulnerable population with respect to suicide. We've very, very vigilant to these issues and extraordinarily committed to the well-being of the students.

When there's a tragedy, there's usually a debriefing and we provide a lot of support. Not only to the family, but also to our staff and faculty who may be involved.

Several of the journal articles focused on the effect of a patient's suicide on a psychiatrist or resident. How do psychiatrists deal with losing a patient?

Just as a cardiologist may lose a patient to, say, a heart attack or an oncologist may lose a patient to an aggressive cancer, psychiatrists may lose patients to suicide over the course of our professional lives. As psychiatrists, we respond exactly as one would expect — as human beings we grieve the loss very deeply, and as physicians we seek to learn and to prevent such a loss in the future. Our training does provide us with support through dialogue with supervisors and intentional and explicit efforts to reflect on our experiences, but we feel the tragedy. We do our best to support the survivors of suicide and to remain vigilant to the possible threat of suicide.

Other Stanford researchers who contributed to the special issue include Alan K. Louie, MD; Rebecca Bernert, PhD; Melanie Hom; Belinda Bandstra, MD; and Ann Tennier.

And: If you're experiencing a mental health crisis, call 1-800-273-TALK to reach a 24-hour help line.

Previously: New surgeons take time out for mental health, Will a steel net under the Golden Gate Bridge deter would-be jumpers?, Stanford researcher examines link between sleep troubles and suicide in older adults and Parents of LGBT kids provide best defense against suicide
Photo by PCT

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