The following is excerpted from How Can I Help? A Week in My Life as a Psychiatrist by David Goldbloom and Pier Bryden.
"Boss, Stan left a message on your inside line. It's important," my assistant Simone says.
Stan, my patient Daryl's cousin, rarely calls except to ask whether some work he is moving Daryl's way is a good idea.
As I listen to Stan's message on my voice-mail, I organize some stuff on my desk. Stan's recorded voice sounds uncharacteristically small and hesitant. He tells me that earlier this afternoon Daryl jumped to his death from his apartment balcony.
Everything is suddenly still.
I play the message several times, listening closely for something I may have missed, but my thoughts are inexorably drawn to my meeting with Daryl two days before, seeing his wrinkled, checkered shirt, his unshaved face, his slow smile.
I sit at my desk, staring out the window, trying to think of the orderly steps of notification and documentation dictated by our policy and procedures manual. Then, in the privacy and silence of my office, I hold my head in my hands and weep.
I don't cry easily or often. This is not my first encounter with suicide in 30 years of practice, but it is the first time with someone I have known so long and, I thought, so well. It is also the first time a patient has died by suicide such a short time after I characterized him as safe. I recall what I now realize were his last words to me, a hand on my shoulder as he turned to leave my office: It's hard.
Daryl had obviously had enough. Enough of feeling that life, in the form of technology, relationships, children, had passed him by. I call Sylvia, his mother. She tells me this was what she had feared most during the decades of Daryl's illness. We speak about his talents, his foibles and the awful toll bipolar disorder took on his life. She asks me to thank everyone at the hospital for what they did for him. Even in her grief, she finds room for gratitude and generosity. She says she will e-mail me details of the funeral and the shiva, and says I am welcome to come by her apartment any time. I promise to drop by after work.
Daryl's words as he left my office intrude relentlessly on my thoughts. Why hadn't I stopped him? Made him sit down and asked him what he meant? I know I am grasping at straws. Though screening for suicidal thoughts and documenting the findings are part of clinical routine, a shorthand evolves that clinicians know well. It may be a facial expression, a way of walking, a pattern of speech – something that sets off alarm bells of familiarity. With Daryl, his typical "tell" when he was depressed was that he couldn't finish a sentence; he was slowed down, frustrated, and tearful. I saw none of that two days ago. I will never know if the thought of suicide was in his mind, undisclosed, then, or whether it seized him today and led him to an impulsive flight off the balcony.
I compulsively review Daryl's tumultuous course of treatment in my mind, ruminating over the choices toward which I steered him, wondering where I failed him. Our relationship involved my having an intimate knowledge of him and his depending on and trusting me. Week after week, month after month, his name appeared in my calendar. Each visit reflected a specific conversation, a joke, a plea for help.
I call my wife Nancy to tell her what has happened. She is also a physician and knows of Daryl from the conversations we share over dinner about our patients. We don't know each other's patients by name, but have found that confiding in each other about patients has helped ease the burden of responsibility. Our dining room, in that regard, is a little like the doctors' lounge that used to exist in hospitals – where colleagues could talk candidly and privately about their clinical uncertainties and quandaries. At the same time, both Nancy and I have had the experience of meeting people who are surprised that we don't know that our spouse is that person's doctor.
Today, Nancy's comfort is instant and real, free of platitudes.
"Dave, I'm so sorry. I know how much you liked him. His poor family – what a blow. And for you. That's terrible."
Nancy knows that I don't want anyone to tell me it is "okay" or "to be expected," because neither is true in this moment. I simply need someone I trust and love to know the intensity of this loss and to relieve me of the sudden sense of being alone and of having failed a patient. Logic and grief are at best distant cousins. I am considered a good psychiatrist. What does Daryl's death say about my skills? Yes, people with bipolar disorder are at a significant risk of suicide. But that's all people with bipolar disorder, being treated or not treated by all mental health professionals. This is Daryl and this is me.
I have studied the small literature on the subject of psychiatrists' responses to patients' suicide, which has grown little over the years despite surveys that suggest that as many as half of all psychiatrists lose a patient to suicide and that about one-third of those endure the loss during their residency training. Sadly, I often have occasion to provide support to trainees and colleagues whose patients have died by suicide. I remind them that what has occurred is in part a reflection of the fact that they chose to treat more severely ill people and that such tragic outcomes are painful but inevitable. Today I feel the limits to the comfort of that perspective.
Every doctor lives with risk. Psychiatrists, however, live with a different kind of risk. Suicides and the rare homicide committed by psychiatric patients are seen as preventable in a way that deaths from pancreatic cancer or a stroke or a lifelong diagnosis of diabetes are not. While an oncologist may be criticized for telling a patient with end-stage cancer that medicine cannot accurately predict how long he or she has to live, a psychiatrist's failing to foresee a patient's decision to die or his or her likelihood of acting violently toward others is viewed more harshly.
Attempts to find more objective predictors of suicidality, both biological and behavioural, have met with mixed success. Although there is evidence for familial clustering of suicide (the Hemingway family being a notable example), no "suicide gene" has been identified. Neurobiological characteristics that have been associated with suicidality – disturbances in the serotonin system or of the hormones associated with the human stress response – are not specific and therefore have limited practical usefulness. In the case of the serotonin by-products we can measure, there is persuasive scientific evidence to link decreased levels of serotonin metabolites in cerebrospinal fluid with serious suicide attempts. But the feasibility of performing spinal taps on patients thought to be at risk of suicide – as well as the limits to the evidence itself – renders this a scientifically interesting finding but not yet one that can change practice or provide psychiatry with a suicide crystal ball. At Daryl's last visit, I had no diagnostic test other than my clinical experience and acumen. Both failed me, and therefore Daryl. And now he's gone.
From How Can I Help? A Week in My Life as a Psychiatrist by David Goldbloom and Pier Bryden. Copyright © 2016 by David Goldbloom, M.D., and Pier Bryden, M.D. Reprinted by permission of Simon & Schuster Canada.