Tyler Black, MD, has been treating kids in crisis as a child and adolescent psychiatrist in emergency department and short-stay inpatient care for the past 12 years and has been researching suicide for about 15 years. He’s a clinical assistant professor in the department of psychiatry at the University of British Columbia in Vancouver and trains dozens of medical students and residents a year. His expertise in the study of suicide started with a clinical interest when he was a resident: as he dove into the literature, he found a number of glaring clinical gaps, myths, and knowledge deficits in medical suicidology.
Here, Black speaks with Judy Melinek, MD, a forensic pathologist and a regular contributor to MedPage Today.
Melinek: Given the recent focus on the mental health stresses currently experienced by healthcare professionals, what are the major risk factors for suicide that may be unique to medical professionals as compared to the general population?
Black: This is a great question — because almost everything in risk assessment is relative. There is no one factor that contributes to suicide. Even when we have very well-known preceding incidents, there are often multiple factors involved. Medical professionals, for better or for worse, do get exposed to some of the toughest scenarios in life. Death, loss of function, guilt, grief, and trauma … these are major stressors!
For a medical professional, these stressors can occur regularly. Especially in healthcare settings, there is a “hero/heroine” mentality. We are chronically and onerously overworked, and we are taught that not asking for or needing help is a sign of strength. For physicians there are also significant issues of licensure; seeking any kind of mental health help, or even admitting that they are stressed, can lead to licensing boards putting up restrictions or prohibiting physicians from working. There is a lot we need to do to improve the culture for medical professionals. The job itself is inherently stressful, so we need to actively combat against its pitfalls.
Melinek: Do you think that the current medical training programs — including medical school and residency — sufficiently address mental health and suicidality? How can they do better?
Black: I do not believe they do. In fact, I believe there is a lot of disappointingly superficial work in this area. I am confident that almost every hospital has some kind of official value statement that they “do not tolerate abuse,” yet medical students, residents, even staff physicians are abused regularly, particularly minorities and women.
In training there is a lot of “we value you” support speech — but, in practice, is it possible for a medical student to say, “hey, I need a week off, it’s been really hard during surgery and my sleep is declining,” and actually get that? Can a resident freely and without any penalty tell their supervisor they are struggling with their work burden and can’t take on another case at the moment? I think anyone working in the system knows there is a large delta between the official answer and what would actually occur.
Mental health includes a number of factors:
- Am I safe (in every sense of the word, including my identity, economy, relationships, and physical being)?
- Do I have good coping systems?
- Do I have any mental health disorders that are affecting me?
- How is my physical health?
- Do I have the supports I need?
- What has happened to me in the past, and how does it affect me today?
Far too often, through our medical training and behind the application of our professional conception of mental health, we focus only on the third factor. “Am I depressed?” Well, you don’t need to be depressed to be struggling with your mental health! I wish there was more focus on all of the factors of mental health, and not this fixation on whether you’re so unwell that you can’t function.
Melinek: Is there a role for other professionals who deal with suicide cases, like geriatricians, pediatricians, or forensic pathologists, to work to minimize the risks in their patients? How do you see that role?
Black: Absolutely. There is a huge role for risk assessment (not risk prediction — we really have to get out of that game as clinicians) and identifying what protective and risk factors need improving. We can always make a difference in someone’s life for the positive. But — and this is a big but — we can’t do it alone.
Suicide is a societal problem. If 100% of people with mental health disorders got 100% better from those same disorders tomorrow, we would still have a large number of suicides. We need to end child abuse. Poverty. Systemic racism. Ableism. Provide everyone with healthcare. End sexual assaults. These are big things, and no single clinician can fix the world. We need a full societal effort to reduce suicide rates.
Melinek: In my experience investigating suicide, I find that only half of the decedents had had contact with medical professionals to address their anxiety, depression, or sleep disorders. What can we do to help the public understand how to access mental health services when there are clear warning signs?
Black: I think the problem is that warning signs are too generic to be of any true use. Someone’s mood changing probably has a positive predictive value of 0.0001 for suicide. There are some slightly better ones, but, really, the issue is often about connection and comfort. If you are worried about someone, talk to them, or talk to someone who is in a position to connect with them. If you are struggling, reach out to someone.
And in these communications we can’t be superficial. “Hi, how’s it going?” can be a true moment of checking in, or it can be the most shallow thing in the world. If I sound really down on warning signs, it’s because I think they probably don’t help much, and I am very sure they give people who have lost loved ones to suicide a ton of guilt. “I must have missed all these signs,” is a common sentiment that I think we put a little too much emphasis on in medicine, by admonishing people all the time to be on the lookout for warning signs.
Melinek: At the last American Academy of Forensic Sciences meeting I attended, there was a presentation about suicide in which a single medical examiner office had noted that a small percentage of decedents had abandoned their pets at a shelter prior to dying by suicide. They then reached out to the shelters and educated the staff about suicide risk factors and subsequently thwarted several suicides in the upcoming year. Can you think of other methods where we can proactively intervene to thwart suicide?
Black: That’s amazing, and I think we need to think more like that generally. Checking insurance policies, asking friends to take care of relatives/pets, declining grades — there are a lot of detection mechanisms out there. It’s a little bit at a time. As long as we don’t put that guilt factor on that I’ve talked about. It’s totally possible for a teacher to think a kid is doing OK, has no problems, and that kid dies by suicide. The teacher didn’t miss anything: there was nothing to see. We want to teach, “hey, if you are concerned, here’s how you can approach it,” not “here are really reliable warning signs that you shouldn’t miss.”
The most amount of evidence we have points to the importance of means reduction. It is not true that if you thwart one means of self-harm, then a suicidal person will just find another way. In fact, the more impulsive types of suicide (gun, bridge, hanging, overdose) have repeatedly and demonstrably been impacted by measures that restrict their access. We have to take means reduction seriously. Gun access is a huge issue here in North America, but it’s other things too. There is no need for an enormous bulk bottle of 500-mg Tylenol. They should be in smaller packages with individual doses, and the usual suspects, like diphenhydramine and acetaminophen/paracetamol, should probably be kept behind the pharmacists’ counter, though with no prescription required.
Melinek: Why is it that every time a famous person dies by suicide, it tends to inspire conspiracy theories that the death was due to foul play? Even though suicide is a fairly common method by which people die, why do we have such a hard time accepting it?
Black: We have a number of narratives about suicide that have been taught to us over and over again by media and societal portrayals:
“Suicide is a moral failing.” This is a key component of many religions, and even in more atheistic societies it permeates.
“They made it look like suicide.” For whatever reason, this is a common plot in fiction, even though in real life, murderers tend to be rather overt about the whole murdering bit.
“Successful, happy people don’t die of suicide.” This idea of the obviously mentally ill person being requisite for suicide is a myth we just can’t seem to shake.
I’m sure all of this plays into the conspiracist narratives around prominent suicides. As you know from your line of work, there is effort required to determine manner of death, and it’s not always cut and dry. But, in my experience, most suicides are quite overtly suicides; ambiguity is simply not as common as people seem to think it is.
Melinek: As someone who has to counsel family members when their loved one dies by suicide, I am frequently conflicted by the desire to help their feelings of guilt by saying, “there’s nothing you could have done,” all the while knowing that data show that suicide can be prevented with intervention. How do you navigate this conflict? How can we help families get past their feelings of guilt and avoid suicide “contagion,” but still speak publicly about how to prevent other suicides?
Black: I think we should look at suicide prevention in the same way that we look at accident prevention. We are never going to achieve 100% success in prevention, but we know things that can help. “There’s nothing you could have done” is true in a large number of suicides. Only 55% or so of suicides would occur with the presence of a reliable risk factor. Our positive predictive value for all risk factors combined is tiny. We do not have compelling evidence that we can take someone who has intentionally committed to die and stop them from carrying through on their plan.
At the same time, we know that if we improve risk factors, we can improve their chance of wanting to be alive. We’ll never know the final decision score — but if we can get back to those big society issues and improve them, we could make a dent. I think too often we draw straight lines to most recent events, and that’s a mistake.
For more information about suicide, or if you or a loved one needs help, call the National Suicide Prevention Hotline at 1-800-273-8255, or check out this website.
Judy Melinek, MD, is a forensic pathologist and CEO of PathologyExpert Inc. She is currently working as a contract pathologist in Wellington, New Zealand. Her New York Times bestselling memoir, co-authored with her husband, writer T.J. Mitchell, is Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner. The duo have also embarked on a medical-examiner detective novel series with First Cut, available from Hanover Square Press.
Last Updated July 01, 2021