When Prevention Is Not Enough: The Importance of Postvention After Patient Suicide

Suicide is a major contributor to premature death in the United States. Death by suicide increased by 35% between 1999 and 2018. After several years of suicide decline between 2018 and 2020, suicide rates increased again in 2021 (1), potentially as a result of the pandemic’s mental health toll. The rate of suicide deaths in 2021 was 14 per 100,000 in the U.S. population (2). Suicide is currently the 12th overall leading cause of death in the United States, but it is the second leading cause of death for those ages 10–34 (3). It is estimated that at least half of all individuals will know someone who died by suicide in their lifetime (4). Patient suicide is an occupational hazard for psychiatrists (5, 6). Over the course of their training or careers, an estimated 51%–82% of psychiatrists (7) and 46.9% of psychiatry trainees (8) will experience a patient suicide.

Suicide prevention efforts have been bolstered to address this public health crisis. Suicide screening, the new 988 Suicide and Crisis Lifeline, Zero Suicide campaigns, social media apps, and research into neurobiological risk and protective factors have burgeoned. Suicide prevention efforts highlight risk assessment, management, and effective interventions (https://www.sprc.org). Despite these important initiatives, some patients will still die by suicide. When providers lose a patient to suicide, the impact can be profound (9). Responses often include grief, humiliation, fear, anger, guilt, denial, disordered sleep, and feelings of professional and personal inadequacy (9, 10). Loss of a patient by suicide has also been linked to burnout, compassion fatigue, and a negative impact on relationships (11, 12). Trainees may be particularly vulnerable to the impact of a patient’s death by suicide, as they are in the process of developing a sense of competence that may be shattered by self-doubt, professional embarrassment, and potential concern about being blamed or censured (9, 10). Having had a patient take their own life may have a significant effect on professional practice as well. Caring for subsequent patients with suicidal ideation may provoke fear, leading to more defensive and risk-avoidant practice, including a lower threshold for referral to an emergency department (ED) for risk assessment and for involuntary commitment of patients when they express thoughts of suicide (13).

A common but frequently unaddressed concern is the high risk for functionally impairing posttraumatic stress disorder (PTSD) in clinicians in the aftermath of patient suicide or adverse outcome (14). Kennedy (15) described PTSD among physicians as an outgrowth of “toxic shame,” explaining “I believe that most physicians have PTSD and that the resulting feeling that physicians ignore most is toxic shame. Shame has been defined as the failure to live up to one’s own expectations. I define shame as a healthy sense that one is limited, and toxic shame as the belief that one is defective” (p. 1113).

Postvention is a term coined by Shneidman (16) to specify interventions to address the needs of the bereaved survivors and caregivers after a death by suicide. Postvention is designed to destigmatize the tragedy of suicide, assist with the grief-recovering process, and serve as a secondary prevention effort to minimize the risk of subsequent suicides due to complicated grief, contagion, or unresolved trauma. Despite patient suicide having been cited as an occupational hazard (5), one study suggested that only 20% of psychiatry residency programs maintain a postvention protocol (17).

Nazem and colleagues (11) highlight the importance of therapeutic risk management as a crucial aspect of psychiatric practice when caring for a patient at risk for suicide. In optimal therapeutic risk management, providers and patient work collaboratively to assess and monitor risk, engage in safety planning, and incorporate interventions to mitigate risk. Even in this “best case” scenario, some patients will die by suicide. Nazem et al. (11) extend the philosophy of the therapeutic risk management model after the death of a patient by suicide to include interventions that can care for the “extended community of affected individuals, including ourselves, both before and after a suicide loss” (p. 235). The immediate aftermath of a suicide loss is an emotionally charged and often chaotic time. Having a suicide postvention plan prepared before a loss occurs can decrease anxiety and allow for more effective necessary action. As Nazem et al. have stated, “To take good care of ourselves, our colleagues, and suicide loss survivors, incorporating proactive planning, consistent open dialogue, empathic support, and outreach after a loss is essential” (11).

Clinical Vignette

Dr. Gomez is a postgraduate year 2 psychiatry resident on rotation at a Veterans Administration (VA) hospital. He was on call in the ED at the hospital that evening. It was a busy evening, and Dr. Gomez was just finishing up his assessment and discharge plan with one patient when Mr. Morgan arrived. Mr. Morgan was a 34-year-old veteran of the war in Afghanistan. As a child, his mother and he were the victims of domestic violence perpetrated by his alcoholic father. Mr. Morgan joined the military right out of high school to escape this abusive situation. He was deployed to the front lines in Afghanistan, where his convoy was attacked and the jeep in front of his was blown up by a mine bomb planted on the dirt road. He was minimally injured, but he was plagued by symptoms of PTSD: flashbacks, hypervigilance, sleep difficulties, and excessive drinking. His long-time girlfriend intermittently “kicked him out” of their apartment when he was too irritable or intoxicated, but she had always taken him back after about a week when he promised to do better.

Mr. Morgan was a “frequent flier” to the ED, and he had multiple brief hospitalizations. He was receiving partial disability payments from the VA for service-related PTSD. He had lost a number of jobs because of poor job attendance, drinking, and disrespect to employers. Mr. Morgan advocated for physicians to “get me 100% service-connected disability” because of his joblessness. Although some physicians had attempted to help him, his treatment team determined that he would likely drink more and become more psychiatrically disabled if he did not have the motivation and daily structure of work. The team connected Mr. Morgan to a supervised work placement, but his attendance was waning, even when transportation came to his house in the morning.

The ED intake nurse gave Dr. Gomez a woeful look when he announced that Mr. Morgan was in the waiting room to be seen by a psychiatrist.

“Good news,” he told Dr. Gomez. “His alcohol level is only 0.1 today. I wonder if his girlfriend kicked him out again and he needs a place to stay.”

Dr. Gomez rolled his eyes. “I have only been on the service 3 months, and I have already seen Mr. Morgan twice in the emergency room. It seems to be the same story—he has a fight with his girlfriend, threatens to take his life, comes here for respite, gets discharged to a shelter, and then she takes him back.”

The nurse replied with a note of sarcasm, “Good luck getting him discharged. He loves it on the psych ward.”

Dr. Gomez provided a routine psychiatric evaluation and risk assessment. Mr. Morgan had been in a verbal fight with his girlfriend, and he said that she “kicked me out.” Mr. Morgan replied to suicide risk questions as he had during prior ED evaluations: “I’m going to kill myself if I’m not hospitalized.” He did not reveal a specific suicide plan and said he did not own a gun. Despite Mr. Morgan’s insistence that he should be hospitalized, Dr. Gomez determined that Mr. Morgan’s suicidal statements were chronic and that he simply needed a place to stay. Dr. Gomez told Mr. Morgan that they found him a bed in a shelter and that they would send him there in a cab. The caseworker would check on him the next day.

“You’ll be sorry!” Mr. Morgan shouted as he left the ED. He did not get in the waiting cab but began running toward the overpass. Before the VA police could catch him, he jumped over the edge to his death.

When Dr. Gomez heard that Mr. Morgan jumped from the bridge, he sat stunned in horror. “Will he be OK?” he queried.

“He was pronounced dead,” the ED attending physician told him. “Dr. Taylor is the psychiatrist attending tonight. She is on her way in.”

Dr. Gomez put his face in his hands and stifled a sob. In his mind, he repeated, “Why didn’t I admit him? I killed him.”

Dr. Taylor stepped into the office where Dr. Gomez sat.

“Hello, Dr. Gomez,” she said warmly, sitting down across from him. Dr. Taylor paused to give Dr. Gomez time to respond, then continued. “I understand Mr. Morgan jumped off the overpass and died.”

At this point, Dr. Gomez could no longer stifle his sobs. “I shouldn’t have discharged him,” he asserted through his tears.

“We do our best, but none of us can really predict what another will do—especially one as impulsive and ill as Mr. Morgan,” Dr. Taylor said thoughtfully. “I just looked this up. Mr. Morgan has come to the ED 100 times in the past 5 years. He was hospitalized 20 of those times. The other 80 times he left with the exact plan you had for him.”

“But this time was different,” Dr. Gomez said helplessly. “I missed it. I shouldn’t have taken the chance with discharging him. He said that he would kill himself this time.”

Dr. Taylor replied, “I think he says that every time. We have a clear postvention plan that you heard a bit about in orientation. I will get us both some cold water. Then we can discuss supports for you, other staff, and family. I will be back in 5 minutes.”

Dr. Taylor returned with a bottle of cold water and a wrapped mint chocolate. “How are you doing?” she asked Dr. Gomez quietly.

“Guilty, sad, incompetent,” Dr. Gomez admitted. “I missed the signs and now he’s dead.”

Dr. Taylor nodded empathically. “Having a patient die by suicide is devastating. I know—I had an outpatient kill themselves when I was in residency. I felt guilty, inadequate, sad, angry, and frightened. It broke my confidence for a while. I even thought of leaving psychiatry. But I’m glad I didn’t. I’ve helped a lot of people, but not everyone.”

Dr. Gomez gazed at Dr. Taylor speechlessly. “What happens next?” he finally asked.

“First, we take care of you. Do you live with someone?” she asked.

“My fiancé,” Dr. Gomez answered. “I talked to her already. She is amazingly supportive.”

“So,” Dr. Taylor continued, “I suggest that she come pick you up, or we can call a driver to take you. But first, we need to complete your ED psychiatric note. When is the last time you saw Mr. Morgan?”

“Well, I saw him angrily take the discharge papers and walk out of the ED,” Dr. Gomez moaned.

“You should write your note like any other ED psychiatric evaluation and end with the discharge plan as of when he left,” Dr. Taylor instructed. “I will write a note about getting a call that he jumped off the overpass and what our postvention plan is. The police will inform his girlfriend and any other next of kin. I have informed the program director, hospital administration, and risk management department.”

“But there are more patients to be seen in the ED,” Dr. Gomez noted anxiously.

“I can see them,” Dr. Taylor said, matter-of-factly. “Most people want to take some time off after a trauma like this. But not everyone. Your program director will call you tomorrow to check in with how you are doing, discuss time off, and review next steps. There will be an incident review. Unfortunately, veterans are a high-risk group for suicide. I doubt you will be called, but refer back to me if the media should contact you. You are not alone in this tragedy. We are a team.”

Dr. Gomez sighed deeply. “Thank you for your support, Dr. Taylor. I . . . I . . . I feel so horrible.”

“I understand, and I’m so sorry you are going through this trauma. Mr. Morgan was very high risk. We can’t hospitalize everyone, and we can’t predict impulsive behavior. You are not alone in this tragedy. We are a team that supports each other in this difficult work.”

Postvention Planning

Postvention refers to the steps taken in the aftermath of a suicide to prevent negative health outcomes and facilitate recovery among the bereaved (18). Postvention efforts are designed to decrease the possible contagion effect of suicide, destigmatize the tragedy, operationalize the confusing aftermath, and promote caregiver healing (19). Despite a dearth of rigorous testing of the effectiveness of postvention programs, several retrospective studies highlight the positive impact of support from peers, superiors, and institutions that serve as both a protective factor and a predictor for adaptive coping strategies and lower levels of emotional, traumatic, and professional impacts (6). Other postvention resources include gathering evidence of effective postvention resources to assist survivors and their families coping with a suicide (19).

One such evidence-based program is the SUPPORT postvention program for professionals after patient suicide (20). Using the model of support for professionals proposed by Scott and colleagues (21), Leaune and colleagues (20) designed a 6-week program designed to buffer the traumatic, emotional, and professional impacts of patient suicide; improve support for exposed professionals; and promote the return to normal functioning in the institution exposed to the patient death. There are four stages in the SUPPORT model (20):

• Stage 1: Emotional First Aid, which includes providing an organizational framework to build a crisis team dedicated to the management of the aftermath of death of a patient by suicide. Stage 1 aims to promote basic emotional first aid and early detection for those who were most affected through local support from peers and superiors.

• Stage 2: Team-Based Intervention, which consists of several hours of debriefing of the traumatic event and its impacts on team members. Stage 2 aims to provide professional emotional aid at an institutional level through an in-depth, team-based debriefing intervention.

• Stage 3: Late Detection and Counseling, which provides support for professionals who have been strongly affected or traumatized by exposure to the suicide death. Stage 3 aims to promote a return to normal functioning in the institution at both the individual and organizational levels.

• Stage 4: Optional Long-Term Support, for those professionals and teams that have been highly and negatively affected by patient suicide.

Nazem and colleagues (11) recommend proactive development of a personalized suicide postvention preparation plan. Their proposed postvention plan includes relevant information for an individual who loses a patient to suicide. Sections include contact information for the insurance carrier, clinical supervisors, professional mentors and peers, and nonprofessional significant others, as well as a section designating a realistic self-statement related to suicide, such as “Because I work with people who suffer unique forms of distress, and because some of my patients will be at risk to die by suicide, the odds are that someday one of my patients will die by this tragic act. This will occur despite my very best efforts and intentions” (11). They also recommend a section that specifies important self-care strategies.

Cazares and colleagues (10) created a flow chart for psychiatric residencies that specifies the flow of communication after the death of a patient to suicide. The initial contact is from the individual who first hears of the suicide to the attending psychiatrist and program director. If the resident who is most affected does not yet know of the suicide, they are sensitively informed. The program director and chief residents inform the rest of the residency program. A process group is planned, and the responsible residents run the morbidity and mortality conference. Agrawal and colleagues (22) provide a practical flow chart of initial, primary, and secondary responses in a residency postvention plan. Henry and colleagues (23) provide a detailed postvention plan that reviews tasks and supports needed for the first 24 hours post–patient suicide, the next 2 weeks, and then afterward. Postvention plans may be created for an individual practitioner, residency training program, and/or institution.

Tips for Preparing a Suicide Postvention Plan(10, 11, 22, 23)

Clearly lay out the steps to take and how to access the resources you will need. Post the plan electronically where it can be easily accessed from various locations.

1. Immediate Response

   1. The first to hear of the death of a patient by suicide will inform the head of the team affected (supervisor, attending, program director, chair of department, clinical director, or other). The head will sensitively inform the patient care team (in person, if possible). The organization will inform risk management. If in solo practice, inform your insurance carrier.

   2. Emotional First Aid: The head of the team coordinates a crisis team to provide basic emotional first aid for the professionals affected. This may include asking employee and community mental health providers with expertise in trauma care to consult and provide support services.

   3. Discuss and provide emotional support and referrals with the family of the deceased, as appropriate. By supporting family and friends close to the patient who died by suicide, providers play an integral role in promoting healing for loss survivors. These actions are also critical for mitigating the risk for negative outcomes in close family and friends, including serious mental health conditions, suicide, and legal action.

   4. Identify sources of immediate support for affected mental health professionals (e.g., family, peers, crisis support, supervisor or mentor support, mental health providers).

   5. Sensitively inform the residents (in a training program) or team members in the workplace of the loss.

   6. Procure coverage of work duties for affected individuals, if necessary.

   7. Discuss medico-legal concerns with risk management.

2. Secondary Response (Arranged by the Head of the Team or Program)

   1. Arrange a debriefing and support group facilitated by professionals.

   2. Ensure appropriate legal guidance and support.

   3. Designate a spokesperson to interface with the media, as needed. Identify resources to assist with following guidelines to share information without increasing the risk of “copycat” suicides (24).

      1. Use nonsensational language and life-promoting terms. Change language from “committed suicide” or “successful suicide” to “died by suicide” or “took their own life.”

      2. Avoid oversimplifying or providing misinformation about the causes of suicide. Provide education about multiple causes, including mental and substance use disorders. Although there are not always warning signs, specify common suicide warning signs and symptoms.

      3. Do not share inflammatory information, and determine the content of your communication on a “what is helpful” or “need-to-know” basis. Respect family wishes about the communication.

      4. Offer hope as well as information and resources about suicide prevention and up-to-date information about treatment options. Share the new 988 Suicide and Crisis Lifeline information.

   4. Offer a connection to other psychiatrists that have lost patients to suicide.

   5. Confirm the provision of appropriate support services.

   6. Provide time and opportunities for group reflection and well-being resources.

   7. Normalize emotional responses. Discuss hindsight bias—the tendency for people to perceive past events as having been more predictable than they actually were. Hindsight bias may increase feelings of guilt for “having missed” some suicide warning signs.

   8. Make decisions about attending the funeral or memorial service. Ask the family their preference for your presence.

   9. Offer recommendations for psychotherapy for the negatively affected individuals.

3. Later Response

   1. Organize an incident review or a morbidity and mortality conference that explores systemic elements for quality improvement. The physician or mental health providers that were most affected by the suicide should help provide information, with a focus on understanding and support (as opposed to blaming and scapegoating).

   2. Provide for regular follow-up and support for affected clinicians. Offer referrals and encourage psychotherapy and/or psychopharmacology for individuals who are demonstrating symptoms of functional impairment.

   3. Set up regular visits with a supervisor, mentor, or other trusted individual to check in and continue to help the affected professionals process their trauma.

4. Enhance Self-Care Strategies for the Affected Practitioner

   1. Make a schedule to regularly spend time with friends and/or family members.

   2. Take time off, as needed. Some individuals need this time away for healing, whereas others find the structure and coworker support at work to be more helpful.

   3. Practice health-promoting habits (mindfulness, physical activity, healthy meals, regularizing sleep).

   4. Schedule time for meaningful activities.

   5. Seek professional help for distressing and functionally interfering symptoms.