Unexpected Death or Suicide by a Child or Adolescent: Improving Responses and Preparedness of Child and Adolescent Psychiatry Trainees

| November 30, 2011 | 0 Comments

 

by Sneha Jadhav, MD; Prakash Chandra, MD; and Vinay Saranga, MD
Dr. Jadhav is a Second Year Child and Adolescent Psychiatry Fellow; Dr. Chandra is a First Year Child and Adolescent Psychiatry Fellow; and Dr. Saranga is Clinical Assistant Professor of Child and Adolescent Psychiatry. All from the Department of Child and Adolescent Psychiatry, University of Kansas Medical Center, Kansas City, Kansas.

Innov Clin Neurosci. 2011;8(11):15–19

Department Editor: Paulette Gillig, MD, Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio

Funding: No funding was received for the development of this article.

Financial Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Key words: overdose by adolescent, suicide of adolescent, suicide by patient, Child and Adolescent Psychiatry Trainee and suicide of patient

Abstract: The death of a young patient is a difficult but universal experience in the field of medicine. It is less common in the field of child and adolescent psychiatry. However, when a child or adolescent patient commits suicide, a child and adolescent psychiatry trainee’s response could include shock, denial, disbelief, sadness, sleep difficulties, rumination about patient’s death, fears of litigation, social withdrawal, and a sense of failure. Trainees generally find themselves dealing with the academic, personal, administrative, and legal consequences of this unfortunate but unavoidable event. This article attempts to review the literature on the experience of patients’ unexpected death, including suicide, on child and adolescent psychiatry trainees.

Introduction

The loss of a child is generally considered the worst possible grief. A traumatic reaction to the death of a child is expected from parents, families, and healthcare providers. The death of a young patient is a difficult but universal experience in the field of medicine. Fortunately, it is a less common phenomenon in the field of child and adolescent psychiatry (CAP). When a patient dies by suicide, CAP trainees might find themselves dealing with the academic, personal, administrative, and possible legal consequences of the event. This article attempts to review the literature on the experience of unexpected patient death and suicide on the psychiatry trainee in general, with a special focus on the CAP trainee.

A Composite Case Report of a Patient Suicide

Emma was a physically healthy 17-year-old female patient in the child psychiatry clinic for four years and was followed by CAP trainees. Emma was diagnosed with mood disorder, polysubstance dependence, and conduct disorder. She had been on multiple medications and her symptoms had waxed and waned over the years without any significant or sustained improvement. Emma had attempted suicide and other self-harm behaviors on several occasions in the past.

The CAP trainee had worked hard to help Emma with medications, therapy, and other resources, and shared a positive therapeutic relationship with the patient. When Emma missed her appointment once during the summer, the trainee was not surprised, as she had done so many times in the past. The next day, Emma’s father called to inform the trainee that Emma was found dead by her friends. The cause of death was found to be overdose on street drugs, possibly suicide.

Despite the initial shock and confusion, the trainee managed to offer his condolences to the father. After a brief consultation with the program director, the trainee decided to keep in touch with the family, attend the funeral with the family’s permission, and be available to them over the next few weeks to provide the family with support and resources for dealing with grief. As the patient was an adolescent, there was a relatively small age difference between the patient and the trainee. This had been beneficial in establishing a strong therapeutic alliance with the patient, but made dealing with the patient’s death harder for the trainee. Feeling somewhat satisfied with fulfilling his professional responsibility, the trainee started becoming aware of his own responses to the patient’s death at a personal level. The overbearing feeling was of disbelief, guilt, isolation, and self doubt. He began to think whether losing this patient reflected on his competence as a CAP trainee.

The trainee was fully supported by the department during this time and was offered every opportunity to learn from this incident. This whole experience was ultimately used in supervision to help the trainee learn how to deal with the painful process of losing a patient through possible suicide.

Epidemiology of Suicide in Children and Adolescents

The tragedy of suicide in children and adolescents is considered a national and global phenomenon. Suicide rates vary from country to country depending on local factors and reporting methods.[1] Suicide is rare in childhood and early adolescence, but becomes more frequent with increasing age. The tragedy of suicide in adolescents is experienced by all countries of the world, with as many as 200,000 youth and young adults ending their life early because of suicide each year.[2]

In the United States, despite all the preventive measures and the constant drive toward increasing vigilance among healthcare providers to identify at-risk youths, suicide is still a major cause of death in children and adolescents.[3,4] Suicide represents 12 percent of deaths each year in the American 15-to-19-year-old age cohort (Table 1). It is the third leading cause of mortality in 15-to-19-year-old youth, and the fifth leading cause of mortality in the 10-to-14-year-old group.[5] Each year, more than 5,000 United States teenagers commit suicide. Suicide rates in adolescents and young adults in the United States have varied in the 20th century.[5] Suicide rates in youth dropped somewhat from the 1990s to 2001, then increasing again in 2005. In 2000, more American adolescents and youth died from suicide than from the combined death caused by cancer, human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), chronic lung disease, pneumonia, influenza, birth defects, strokes, and heart disease.[1,6,7]

Table 1 shows the data of causes of death in 15 to 24 year olds in 2000.[1,6,7]

Epidemiology of Patient Suicide and Trainee Psychiatrists

Patient suicide is a relatively common event in mental health. A limited number of cross-sectional studies have looked at the lifetime incidence of experiencing patient suicide among mental health workers. Eighty-six percent of staff across various disciplines had experienced patient suicide.[8] At some point in their careers, most psychiatrists will lose a patient to suicide during the course of treatment. A national survey of 586 randomly selected psychiatrists in the United States found that 51 percent of the 259 respondents had experienced at least one patient suicide in their career.[8] There was no difference in terms of age or years of practice between those who had and had not experienced patient suicide. In general, postgraduate training was associated with a lower rate of patient suicide. Forty to 50 percent of psychiatric trainees reported to have experienced at least one patient suicide during their training in one study conducted in the United Kingdom.[9] In 2000, Alexander et al[10] approached 128 trainee psychiatrists in Scotland, with 47 percent of the 103 respondents reporting the suicide of a patient who was under their care; the number of suicides experienced ranged from 1 to 5. In addition to the 47 percent who reported direct experience of patient suicide, a further 40 percent had been involved in the consequences of suicide (e.g., the suicide of a patient who was not directly under their care).

Henn et al[11] reported that 60 percent of third- and fourth-year residents were unaware of the suicide deaths of patients they treated professionally, even though the deaths were registered as such by the coroner’s office (an estimated ratio of known to unknown suicides of 1:12). In another study conducted in 2001, Courtenay and Stephens[12] sent a postal questionnaire to 400 trainee psychiatrists in the South Thames region of England. Of the 203 who responded, 54 percent reported experiencing at least one patient suicide; of this group, 39 percent had experienced more than one, and the total number of suicides experienced ranged from 1 to 7.

The effects of patient suicide on psychiatrists are rarely discussed, and research literature on this topic is relatively sparse. Most of the literature on this subject pertains to suicide of adult patients or experiences of general adult psychiatrists.[13] Specifically in child psychiatry, this issue has received little attention. There are few articles in the literature that have focused on the experiences of child and adolescent psychiatry trainees following the death of a child or adolescent patient through suicide.

Effects of Patient Suicide on Psychiatrists

The effects of patient suicide on psychiatrists can be prolonged and profound. Research and anecdotal evidence suggest that coming to terms with the suicide of a patient can be extremely distressing for front-line professionals. As with any traumatic event, psychiatrists use a range of different coping mechanisms in the aftermath of patient suicide. Some research also suggests that exposure to such situations can undermine professionals’ functioning and feelings of competence, cause them to question their professional standing, and ultimately contribute to burnout.[13,14] A survey of 447 front-line professionals’ experiences of patient suicide was undertaken to further explore these issues.[11]

Thematic analysis of open-ended questionnaire items revealed that concerns for the bereaved family, feelings of responsibility for the death, and having a close therapeutic relationship with the patient are key factors that influence the adjustment and coping of a psychiatrist in the aftermath of the death of a client by suicide.[9] Deary et al[15] have shown that psychiatrists are more emotionally exhausted and have higher levels of depression than their medical and surgical colleagues. Patient suicide and the risk of patient suicide undoubtedly contribute to this exhaustion and depression among them.[15] A significant personal and professional effect has been seen on psychiatrists following a patient’s suicide (Table 2).

Alexander et al[11] found that 33 percent of the attending psychiatrists who had experienced at least one patient suicide reported an adverse impact on their personal lives, characterized by irritability at home, poor sleep, low mood, and decreased self confidence. Forty-two percent also reported an impact on their professional practice, characterized by greater use of suicide observations, more detailed note keeping and communications, lower thresholds for using mental health legislation, and more defensive approaches to patient risk. Fifteen percent of attending psychiatrists considered taking early retirement as a result of patient suicide.[11]

Giltlin et al[16] provide a particularly valuable account of a psychiatrist’s reaction to a patient’s suicide, characterized by symptoms of post-traumatic stress disorder (PTSD); feelings of anger, shame, and isolation; and fears of litigation and retribution resulting in substantial self doubt. Gitlin et al goes on to discuss the factors that come into play when a psychiatrist is faced with a patient suicide: the quality of the relationship between the doctor and patient, the psychiatrist’s own psychological make-up, and his or her level of training.

According to a recent study,[17] the impact is more severe when patient suicide occurs during a trainee’s training, and is inversely correlated with the clinician’s perceived social integration into his or her relational professional network. Also, the impact is inversely proportional to clinician’s age.[17] In a 2004 study by the American Foundation of Suicide Prevention, Hendin et al[18] identified several factors as sources of distress for mental health professionals after patient suicide (Table 3).

Other Residency Trainees Dealing with Patient Loss

In a national survey of 1,500 obstetricians,19 it was found that perinatal death has a profound effect on the delivering obstetrician. A significant number of participants had considered giving up obstetrics all together because of the emotional difficulty in caring for a patient with stillbirth. Another study[20] assessed the psychological effect of adverse maternal or fetal outcomes and malpractice claims on obstetricians and gynecologists. Six-hundred and fifty-four [responders out of n=897] practitioners across the country were involved in the study. Twelve percent of these practitioners had experienced fetal death, which caused psychological trauma, job stress, perceptions of shame and doubt, and triggered active coping mechanisms (e.g., discussing with colleagues or spouses, seeking ways to avoid recurrences).

Effects of Patient Suicide on the Child and Adolescent Trainees

Patient suicide during the CAP residency/fellowship training may be one of the most difficult, but also one of the most educational learning experiences. Upon learning that a patient has completed suicide, trainees’ responses could include shock, denial, disbelief, sadness, irritability, social withdrawal, poor concentration, sleep difficulties, rumination about patient’s death, fears of litigation, and a sense of failure.[4,21] Several questions may immediately come to a trainee’s mind, such as “What did I miss? Was there something I could have done differently? Do I call the family to offer condolences?” or “Should I attend the funeral?” These questions might lead a trainee to low self esteem or self confidence, shame, and feeling isolated from the professional community.[21] Repressing emotions could lead to stress, distancing from families, burnout, and compassion fatigue.[22] The death of a child or adolescent patient can be particularly difficult on a trainee, since there is a sense of loss of what the child “could have become,” which might lead to a long-lasting guilt.

Patient Suicide and the Role of CAP Training Programs

A vast majority of the psychiatry training programs (91%) in the United States offer formal teaching on suicide care.[23] Grand rounds (85%) and case conferences (80%) are popular methods for teaching this topic to trainees. However, in a national survey of psychiatry chief residents, Melton and Coverdale[23] found that only 19 percent of chief residents felt prepared for the possibility of having to manage the aftermath of a patient suicide. The majority of training programs offer some form of training in dealing with suicidal patients, but there is much variability in the curriculum, style, and emphasis of teaching.[24] Some suggestions for interventions in the aftermath of suicide by a patient are listed in Table 4.

Recommendations for Trainees in the Aftermath of a Patient Suicide

Considering the significant psychological impact of losing a patient, the trainee should be encouraged to speak to a supervisor for support and feedback on how to handle the situation.[25] Trainees should be educated to communicate clearly, empathically, and respectfully with patient’s parents and families. The surviving family should be referred to a grief counselor, social worker, or clergy for support. Trainees should also follow up with bereaved parents and families for questions or concerns.[25] If the family gives consent, the trainee may attend the patient’s funeral, which can show empathy for the family’s loss.[26] If the trainee does not feel comfortable attending the funeral, a sympathy card may be sent instead.[27]

Conclusion

Patient suicide is a significant event in the field of psychiatry. When the patient is a child, the personal and emotional component of experiencing a patient’s death becomes more profound. It strongly affects the professional and personal lives of the CAP trainees. Patient suicide in the initial stages of CAP training can be very difficult, but it is a good educational and learning opportunity for the trainees. During such an unfortunate but unavoidable process of dealing with losing a patient, CAP trainees should seek appropriate supervision and support at all times.

References

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Category: Child Adol Mental Disorders, Mental Disorders, Mood Disorders, Neuro oncology, Psychiatry, Psychology, Psychotherapy Rounds, Suicidality

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