Resident friend joked about suicide

[Longtimelurker12]

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To all,

I am a long time lurker here since I once was interested in applying to medical school (I went to grad school in a different route).

I have a friend who is going through residency. I am extremely concerned about him. He has been getting increasingly sad and short tempered as the year progressed. I thought at first that it was just regular residency blues. A few weeks ago, however, he scared me by joking about committing suicide.

He lives alone, is fairly new to town, has very little if any family support, has significant debt (a source of stress and sadness), and does not have a significant other (which is another and even larger source of stress and sadness for him). He has lost interest in doing things that used to give him joy. He does not seem to have any close friends outside of his residency. He forces himself to put on a happy face in public (I think perhaps because he's terrified of someone finding out that he might have depression). After the suicide "joke", I offered him to live at my place (he politely declined) and made him promise me that if he ever decides to kill himself that he would call me first to say goodbye (the idea being that I would try to talk him out of it). In the meantime, I write him encouraging emails (since he doesn't have time for face to face meetings). I also am good at baking, so I send him cookies, which he happily shares with his co-residents (I'm hoping it will help him make more friends at work).

I seriously think he needs help but I don't know how to do it without his PD knowing and I don't want him to lose his career over this. Is there any way I could convince him to seek help without him risking his career?

-- A concerned friend

 

[SouthernSurgeon]

1. Please, please do not take this lightly. There are a number of horribly tragic stories of residents committing suicide. Mental illness is shockingly common among med students and residents, and this time of year is a particularly low point for many.

2. Have you reached out to his family? or any other close friends? Even if he doesn't feel close to them...Is it possible to get anyone else involved in this?

3. Be direct with him. Express your concerns. Show him and tell him that you care about and love him. Encourage him to seek professional help.

4. SDN is not a place for professional advice.

 

[Dral]

Calling you to say goodbye in hopes to talk him out of it is probably not the best approach. You must 'contract' him, meaning that he agrees that if he ever seriously thinks of harming himself, he is instead to immediately call 911 or go to an emergency room.

 

[QofQuimica]

If you're at all worried that he might really be suicidal, then get off the computer now, and either take him to the ER if he'll go with you (preferably not at the hospital where he works), or call EMS and let them take him to the ER. They will evaluate him there and decide if he needs to be hospitalized. Even though he's a physician, you can't count on a depressed person to make a logical decision about whether they need help; that lack of perspective/insight is part of the disease. And while he might not be happy with you forcing him to go to the ER, if you're going to err, better to err on the side of over-reacting than under-reacting. You may wind up saving his life.

 

[tartesos]

To all,

I am a long time lurker here since I once was interested in applying to medical school (I went to grad school in a different route).

I have a friend who is going through residency. I am extremely concerned about him. He has been getting increasingly sad and short tempered as the year progressed. I thought at first that it was just regular residency blues. A few weeks ago, however, he scared me by joking about committing suicide.

He lives alone, is fairly new to town, has very little if any family support, has significant debt (a source of stress and sadness), and does not have a significant other (which is another and even larger source of stress and sadness for him). He has lost interest in doing things that used to give him joy. He does not seem to have any close friends outside of his residency. He forces himself to put on a happy face in public (I think perhaps because he's terrified of someone finding out that he might have depression). After the suicide "joke", I offered him to live at my place (he politely declined) and made him promise me that if he ever decides to kill himself that he would call me first to say goodbye (the idea being that I would try to talk him out of it). In the meantime, I write him encouraging emails (since he doesn't have time for face to face meetings). I also am good at baking, so I send him cookies, which he happily shares with his co-residents (I'm hoping it will help him make more friends at work).

I seriously think he needs help but I don't know how to do it without his PD knowing and I don't want him to lose his career over this. Is there any way I could convince him to seek help without him risking his career?

-- A concerned friend

Depression is treatable and he may need treatment. That may have been his cry for help.
Try offering to go with him to a mental health professional and book the appointment yourself?
As a last resort committing him if need be, beats the alternative which is not doing all you could and carry this guilt forever if he succeeds( and men are more efficient at suicide than women are).

Good luck!

 

[Siggy]

Calling you to say goodbye in hopes to talk him out of it is probably not the best approach. You must 'contract' him, meaning that he agrees that if he ever seriously thinks of harming himself, he is instead to immediately call 911 or go to an emergency room.

I was under the impression that no-suicide contracts weren't evidence based and, in reality, did more harm than good (false sense of security).

 

[Dral]

I was under the impression that no-suicide contracts weren't evidence based and, in reality, did more harm than good (false sense of security).

That's interesting. Do you know of any manuscripts or current rec documents on the subject? I'm in a field where I don't need to do it often, but would definitely like to know if recs about it have changed.

 

[Doctor Bob]

I was under the impression that no-suicide contracts weren't evidence based and, in reality, did more harm than good (false sense of security).

I've wondered about that. I wonder what the penalty is if they breach the contract?
"You promised not to kill yourself... but then you did. So according to the penalty clause in your no-suicide contract you owe us $100"

 

[wholeheartedly]

Sorry you're having to deal with this. I know its not a fun position to be in.

I had to call my ex girlfriends mom in the middle of the night and tell her that her daughter was suicidal and needed help and I was too far away to drag her there myself. The ex was pissed at me and didn't talk to me for awhile, but she's still here a decade later.

She'd been struggling for awhile and had mentioned suicide before and I had tried to push her to get help, but that night was the night I really thought she might actually go through with it. I stayed in the phone with her for hours and when I finally hung up, just had this sick and powerless feeling being on the other side of the country.

Sometimes you just have to bite the bullet and drag them to help kicking and screaming. In his case preferably far away from where he works.

 

[link2swim06]

That's interesting. Do you know of any manuscripts or current rec documents on the subject? I'm in a field where I don't need to do it often, but would definitely like to know if recs about it have changed.

I have heard the same thing. Nothing is really there to encourage them to stay within the scope of the 'contract' if they are acting irrationally enough to commit suicide.

 

[j4pac]

There is something called "ASIST". Read up on it.

It teaches to be direct with someone and ask the person if they are going to kill themself or commit suicide. Verbage is important. You don't ask if someone plans on "hurting" themself. Suicide is often seen as a way to take the hurt away.

 

[QofQuimica]

All this discussion of suicide contracts, while academically interesting, is beside the point. The OP is presumably not any type of mental health professional and has nothing to be gained from trying to act like one. His/her role should be to get this friend to someone who has the knowledge and expertise to make the determination of whether the friend is suicidal. I'm a licensed (non-psych) physician, and I wouldn't consider myself qualified to make the decision of whether someone is so unstable that that need psych hospitalization. To ask the emotionally involved layman friend of a depressed person to do it is even more ludicrous. That's why we have a Baker Act here in Florida (and its equivalent in other states) that lets hospitals hold someone who may be a danger to themselves or others for up to 72 hours until a qualified MH clinician can assess them. Hopefully the OP has already brought the guy in to be seen.

 

[eastcoastdr]

As a psych resident, I agree with most of what has been said above. Urge your friend to see a MH professional - maybe someone who's NOT at the hospital he works at. The MH professional who evaluates him can decide if he needs outpatient vs. inpatient treatment. I know at least in my state and a few others, patients can be taken into the hospital against their will if the doctor feels they are a danger to themselves or others. I know he's worried about his program finding out, but tell him that he is risking more by continuing to work when he's not the right state of the mind. If he takes control of the situation now and seeks treatment, he could ask for a temporary leave or vacation from his PD without having to divulge reasons. He doesn't want to get into the type of situation where his program forces him to leave for a little while because they notice something's up with him. And tell him that there's a way for him to feel better, and that you are there to support him.

Another thing you could do is go over a crisis plan with him - we do this with many of our patients. Make sure he knows what resources are available to him if he ever feels like harming himself. Like calling 911, going to the ER, calling a suicide crisis hotline, calling you or a family member, etc. And if at anytime you feel like he is danger, don't hesitate to call 911 yourself.

Regarding suicide contracts - I've always been taught by my attendings that "suicide contracts" don't work unless you already have a positive, long-standing therapeutic relationship with the patient. Suicide contracts on their own don't hold up in court either, meaning if someone writes a psych assessment and puts "Pt contracted for safety" as the only supporting statement for why they think a patient is not suicidal, and the patient goes and kills themselves they can still be liable. If you assess someone's risk of completing suicide and list other more supportive things like "patient is future oriented, has family members that will stay with her after discharge, etc" and then also put "patient contracted for safety" then that's fine.

Good luck!

 

[DermatoFIGHT]

Sometimes, when someone is down this way, they need to be surrounded by good positive people to help them get through it. Depression is really tough and you do not think the same as you would when you are not down. I am assuming your friend is in a cold environment (north midwest?). Medicine can consume everything in your life and when life isn't fair (as it usually is not) one may feel hopeless. Best is to get your friend up and out of the house doing things together and experiencing some fun events and memories.

My guess is your friend has only rough and sad memories of medicine training, having some positive experiences can really make things that much easier. Wish you both the best.

 

[Longtimelurker12]

Thanks for all of your feedback. Update: I have spoken to my friend about the suicide joke, especially as he has made another suicide joke shortly after the first. The problem: he is in denial and looked absolutely terrified when I told him that I think he has a problem and needs help (I think because of the prospect of possibly being kicked out of the program and I don't know if a temp LOA is financially feasible for him at the moment). He was very upset and evasive when I tried to bring up the subject and does not appear to want to seek help, even when I told him that I know some very good therapists who are not associated with his program. He has since stopped talking to me and expressed that he no longer wishes to have face to face contact with me. I want him to get help but I don't want to be accused of harassment. I do not know any of his coresidents or family members because he's never introduced me to any of them. I know that he is not very close to his family.

 

[rokshana]

Thanks for all of your feedback. Update: I have spoken to my friend about the suicide joke, especially as he has made another suicide joke shortly after the first. The problem: he is in denial and looked absolutely terrified when I told him that I think he has a problem and needs help (I think because of the prospect of possibly being kicked out of the program and I don't know if a temp LOA is financially feasible for him at the moment). He was very upset and evasive when I tried to bring up the subject and does not appear to want to seek help, even when I told him that I know some very good therapists who are not associated with his program. He has since stopped talking to me and expressed that he no longer wishes to have face to face contact with me. I want him to get help but I don't want to be accused of harassment. I do not know any of his coresidents or family members because he's never introduced me to any of them. I know that he is not very close to his family.

you need to see if there is program or someone who helps residents who need help...he needs help...if all else fails, you need to voice your concern to his PD...better you lose a friend who is alive than keep a dead one...

 

[QofQuimica]

Thanks for all of your feedback. Update: I have spoken to my friend about the suicide joke, especially as he has made another suicide joke shortly after the first. The problem: he is in denial and looked absolutely terrified when I told him that I think he has a problem and needs help (I think because of the prospect of possibly being kicked out of the program and I don't know if a temp LOA is financially feasible for him at the moment). He was very upset and evasive when I tried to bring up the subject and does not appear to want to seek help, even when I told him that I know some very good therapists who are not associated with his program. He has since stopped talking to me and expressed that he no longer wishes to have face to face contact with me. I want him to get help but I don't want to be accused of harassment. I do not know any of his coresidents or family members because he's never introduced me to any of them. I know that he is not very close to his family.

You need to s*** or get off the pot. If you decide to get involved, then call the local police and send them to his house for a wellness check. They will call EMS and bring him to the hospital to be assessed if necessary. Yeah, he's gonna be upset with you if he winds up getting committed. But he's already not speaking to you, and I wouldn't let that deter me if I was really worried about him being suicidal. If you're not worried enough to call emergency services, then leave the guy alone.

 

[deleted480308]

You need to s*** or get off the pot. If you decide to get involved, then call the local police and send them to his house for a wellness check. They will call EMS and bring him to the hospital to be assessed if necessary. Yeah, he's gonna be upset with you if he winds up getting committed. But he's already not speaking to you, and I wouldn't let that deter me if I was really worried about him being suicidal. If you're not worried enough to call emergency services, then leave the guy alone.

I agree, if I were him and actually not suicidal I would never talk to you again either if I thought you were about to try and have me committed. And if I was sick, I would probably react the same way

Either save him if he needs it or leave them alone if they don't, but the casual friendship is done

 

[Call Me Dr.]

Any updates?
Suicide is a real risk for physicians. Just got another notice for a suicide of a physician in my specialty in my state. Your friend needs help. Your friend might need you to show up on their doorstep. When I faced severe depression including suicidal ideation during training, I needed help and, even more importantly, I needed someone to stay with me so I wasn't living alone.

 

[freemontie]

The most important question: in what context was the joke? Was he drinking? How did he act when you confronted him later about the joke? Was he surprised?

 

[Crayola227]

Unfortunately, the reality is that anything that this resident does to make this better will likely make things worse unless they are able to pull themselves away form the edge without anyone knowing. The absolute best thing they can do is keep this a secret from their program, colleagues, state licensing board, and even the state Physician Health Program, PHP. If this comes out, it will likely just end up hurting their career in some fashion thereby adding to the misery. A suicidal resident might rather commit suicide then go to the ED and then get hospitalized and then have to face the board. Could that save their life? Sure. Could it make things worse? Yes.

What they should do is talk to the program and colleagues or whoever to find out who is a good Primary Care doc that is known for treating residents with discretion (without mentioning for what medical issue the resident is wanting a PCP for), and from that person finding a good psychiatrist that is discreet and and used to working with physicians, and also a referral for counseling. Once they have established with a PCP to obtain these contacts, they can then try to make further appointments around their days off, or if necessary try to work it out with the program/chiefs/seniors/attendings going to these appointments on occasion without letting anyone know it is for mental health. They need medical, psychiatric, and counseling care for their depression that is discreet. You may be able to help this resident by doing some of this legwork for them. You could find out what their insurance carrier is, then from who would be covered figure out what providers are not affiliated with their place of employment, has a separate health records system, and then call those providers and see who might fit this bill of treating a physician discreetly and if they're taking patients and what their hours are. Bonus points if you can find out the residents schedule and make the first appointments for them that fit in.

This would lower the activation energy for the resident, as they would not have to try to do this legwork after 80+ hours at work (plus they can't get anything done M-F 9-5 on their own behalf, and even if their day off is a weekday they're probably going to be too overwhelmed anyway), and hopefully if all it takes is them showing up to a discreet secret separately affiliated no EHR sharing PCP reputed to be nice for other docs to see, they would at least show up and get in the system that way.

I do not mean to say that this resident should not do or receive whatever it takes to save their life, just that the path of getting treatment that DOES NOT open the Pandora's box of the entire medical system turning on them for having a mental health problem (the system is designed to save the public from mentally ill physicians, the primary mission is NOT what is necessarily best for that physician) may be safer than a path of treatment.

Many many I know have gone down the officially endorsed paths we're told for treating mental health issues in medicine, and almost all have suffered more than if they had managed to get treatment secretly. Either ask for time off and get outpatient treatment, or get outpatient treatment, but as much secrecy as possible from all associated with work is key. If you have to get inpatient treatment, then do it, but the best course of action however is for your trusted psychiatrist to send you out of the state of practice if at all possible. I may be able to get some program names.

For anyone who thinks I'm full of crap, I refer you to google Dr. Pamela Wible on the issue of physician suicide.

There by the grace of God I hope you may all go.

 

[Crayola227]

Also I agree that not being alone is key. They declined staying at your place, perhaps you or someone they love might insist on staying with them? That can do a lot of good. So can pets. Cats are an ideal resident companion.

 

[Crayola227]

Sorry, I just read the part where you said your friend was evading you. I would encourage you to get anyone you can to help this resident, but stay away from their program finding out as much as you safely can.

 

[moonwake]

It might sound cliché but has he considered anti-depressants? Had a cousin commit suicide last year and I wished I would of asked if he was on them.

 

[Crayola227]

It might sound cliché but has he considered anti-depressants? Had a cousin commit suicide last year and I wished I would of asked if he was on them.

Here's a teaching point:
Antidepressants are not vaccines to suicide. A lot of factors goes into mental health, and remember most studies show talk therapy to be equivalent to pharmacotherapy in improving depression, and both together are more effective. As I said above, being plugged in with other humans is going to be game changer.

A very important teaching point:
Many antidepressants, especially more "activating" ones, SSRIs, SNRIs, wellbutrin, etc etc
have blackbox warning that they may INCREASE risk of suicide especially at outset of therapy
yet another reason that you need good follow up and support, people's depression is not likely to get better in a vacuum with a box of pills
Can have a paradoxical effect in that they may increase motivation, maybe impulsivity, BEFORE improvement of mood
meaning, I'm just as sad as I was before, but I didn't feel decisive or enough motivation to really act on my suicidal feelings, but now that I'm energized by these pills, maybe having more disturbed sleep (an issue with antidepressants) now I'm finally feeling the oomph to climb this building and jump off
another reason that there while there are increased suicide attempts during the winter holidays, and Seasonal Affective Disorder, those same SAD'ers can have an uptick in attempts in Spring, as the days lengthen
light really does have an effect on circadian rhythms and mood and motivation, and some of these guys get antsy before they feel better

Last point:
If you are not careful with history, family hx, and screening for hypomania/mania in a patient (they will NOT necessarily think to remember to tell you that 5 day trip with no sleep in Vegas blowing ten grand and buying hookers when they come to you very very very sad, the good times are often not prominent in their minds at this point), or that Daddy had such episodes, unless you ask, and if you're not careful you will give a Bipolar/potentially bipolar patient that's depressed a mixed episode/mania, depression now with a good touch of impulsivity, and possibly precipitate their suicide or other life implosion

Remember, first, do no harm. Chat a bit before you write that script.

Sorry, just that some studies suggest up to 10% of clinic patients seeking help for depression are bipolar/undiagnosed. So I hate the knee-jerk reaction for SSRIs. Please keep this in mind, do a good history, and have close follow up. Especially if they are at higher risk for hypomania. You need to see how far in wacko land they are in 2 weeks.