A young man’s life is over too soon. He had been seen more than four times by more than ten different physicians and in four different clinical settings in the two weeks leading up to his death. Each time he was accompanied by a concerned loved one. Each time his depression was discussed in detail. Each time a medical professional determined that it was safe to send him home. Yet, somehow, he successfully committed suicide within days of being discharged.
He was my patient, and I knew him well. He was 33-years-old and father to two young children. He openly admitted to being suicidal and spent time in emergency rooms, hospitals, an inpatient psychiatric center, and a drug rehabilitation center, at times willingly, other times against his wishes. I wanted him to be safe. His family was desperate for help. Doing all the right things and sending him to all the right places just wasn’t enough.
The loss of a loved one to suicide is devastating to families, physicians, and entire communities. In medicine, we continuously strive to improve the health of our patients through lifestyle interventions and medications. But we often overlook the importance of involving family members in our efforts to prevent suicide. As a primary care physician, I encounter people struggling with mental illness and suicidal thoughts on a daily basis, yet I have learned that I must rely on the friends and family members of my patients to protect them when I am unable to.
According to the American Foundation for Suicide Prevention, in 2017 at least 1.4 million Americans attempted suicide, and of those 47,173 died, making suicide the 10th leading cause of death in the United States. While these numbers are frightening, what is more startling is that nearly 50% of suicide victims had seen their primary care physicians in the 30 days preceding their deaths. These findings suggest that even well-meaning physicians following guidelines and “doing all the right things” is not enough when it comes to preventing deaths from suicide.
As physicians, we have limited control of our patient’s home environments. We should stress the importance of family involvement when managing depression. Some people fear that asking about suicide could induce ideas of self-harm. As physicians, we should tell families that the truth is that not talking about this issue leads to more deaths from suicide. Family members and caregivers should be educated about risk factors and warning signs of suicide. They should be encouraged to explicitly ask about any thoughts of self-harm when checking in with a loved one about depression. While it is standard practice to discuss risk reduction with patients and their families, it is not always done in a way that both encourages companions to play an active role in observing behaviors and provides practical information for how and when to intervene.
I urge all physicians treating depression to train parents, spouses, siblings, and friends of your patients to ask their loved one, “Have you had any thoughts of hurting yourself?” Please tell your depressed patients that you will be checking in with their family members. Then provide a way for them to call or reach out to you if they have concerns about your patient’s depression. Ask your depressed patients about suicide at every visit. Ask them if they have someone they trust who they could reach out to if they developed suicidal thoughts. These strategies can lead to a candid discussion about suicide between you and your patients but also between your patients and their loved ones.
Once the diagnosis of depression is made, the risk for suicide must be evaluated and followed longitudinally. If suicidality has been expressed, an open and honest dialogue between loved ones can be the difference between life and death. It is our job as physicians to enlist the help of those people who are with our patients when we can’t be.
RaeLeigh Payanes is a family physician.
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