When I was a senior psychiatric resident I was approached by an attending psychiatrist to cover for him —that is, be available to his private patients—while he went away on vacation. It was a common practice. This courtesy was advantageous to the residents since they would charge for seeing these patients once or twice, if they needed to be seen. At the same time the attending psychiatrists could feel certain that their patients would be cared for in an emergency if they could not be reached. And when they were on vacation, they were rarely reachable.
I did not know this particular psychiatrist, and I’m not sure he knew who I was when he poked his head into a staff room and saw me. He asked me if I was available during the two weeks he was going to be on vacation; and I told him I was. He told me his patient’s name and took my name and telephone number to give to her.
“...Oh, just one thing,” he said before leaving. “Her previous psychiatrist killed himself when he went on vacation; so she’s a little nervous about it.” He smiled. “Just tell her I’m coming back.”
The woman never called me. I found out a few weeks later that the psychiatrist I was covering for, who spoke to me so calmly that day, killed himself during his vacation! He went out on a boat and swam away from it until he drowned.
I have to admit that my reaction to this news was not to feel the sympathy I would have expected to feel for someone so distressed that he would attempt—and in this case succeed—in committing suicide. I was angry. I kept wondering what his patient was thinking. I thought that he had a responsibility to her, no matter how terrible his emotional distress. If he was determined to kill himself, he could have done it later on, after discharging his patient to someone else’s care. That was what he ought to have done, it seemed to me.
There is some validity to this point of view. Over the years I have heard a number of patients tell me convincingly that they would have killed themselves if it weren’t for their children. Some hesitate to kill themselves because their religion instructs them that such an act is wrong. It is true that even at such desperate moments—when life seems intolerable—there is some sort of control. But many times—especially in those situations where a suicide attempt is successful, those considerations seem not to matter. A parent may hang himself where his child is bound to find him. I know of a suicide that took place on a child’s birthday. It is known by many that when a parent has killed himself, or herself, there is a greater likelihood of their children someday committing suicide. But these facts and circumstances do not enter into their parent’s calculations when they set out to kill themselves.
Sometimes the terrible pain of living overshadows everything else. I have seen a depressed man who had responded to anti-depressant medications during two previous depressions—and who had good reason, therefore, to think he would respond to them again--and yet in the midst of a third depression made a serious suicide attempt. The awfulness he was experiencing was so overwhelming, it seemed to him it would never go away again. The fact that he had recovered previously did not matter.
I do not think the suicidal psychiatrist I mentioned above was callous or uncaring. I do not think he was contemplating suicide when he spoke to me. But suicidal feelings can come on suddenly and unpredictably and, in some cases, at least, irresistibly.
One might think, naively, that psychiatrists, who are expert in these matters, might be better able to understand and resist suicidal urges; but they cannot. It was reported a long time ago that among the different medical specialties, those who practice psychiatry have the highest proportion of successful suicides and pediatricians the least. Why should that be? Is it really true? Is there some aspect of personality that leads one physician to choose one specialty and another physician a different one? And does one type of personality incline someone to suicide?
I have often thought that if I had not become a psychiatrist, I would have liked being a radiologist. What radiologists do is search an X-ray, like a detective, looking for clues to hidden diseases. That seemed appealing. If I had become a radiologist, would that have made me less vulnerable? I would not have liked being a surgeon, which seemed mechanical to me—or an anesthesiologist, who does the same thing more or less every day and has to worry that someday, unpredictably, one of his patients will die. Oncology is still less appealing. Oncologists spend most of their time taking care of dying patients. Some pathologists become medical examiners and address themselves exclusively to dead people! Why do they choose to do the things they do? There is nothing obviously distinctive about their personalities. Still, I think there is a common denominator that motivates all physicians.
I had already made up my mind to be a psychiatrist when I was an intern. Most of the time I worked on the psychiatric ward; but I also rotated through other services, including neurosurgery. The patients on neurosurgery were appalling to me. Their symptoms seemed overwhelming. One woman’s eyes moved in and out together as if they were connected by a rubber band. Others could not talk or walk. Still others were unresponsive and had been unresponsive in some cases for weeks. I felt there was nothing I could do to help them.
The resident I worked under was in training to become a neurosurgeon, and like other residents, was called sometime to other wards to provide consultation to other physicians. One day he returned from seeing a patient on the psychiatry ward and said to me: “Fred, I don’t know how you can work with those people, there’s nothing you can do to help them.”
If this resident and I were different kinds of people, it was not apparent to me. We even shared the same desire that motivates most doctors: the desire to help sick people.
It may not be true that psychiatrists are more vulnerable than other doctors to suicide. Recent studies contradict the earlier ones. What seems unequivocally true, however, is that physicians in general kill themselves at twice the rate of the general population. Why should that be?
If, in fact, psychiatrists in particular are to some extent inclined to suicide—more than other doctors, and other people—and I think it is true—there are only two possible explanations:
- That the sort of people who choose to go into psychiatry are, for reasons of personality, the sort of people who are in the first place inclined to suicide.
- That there is something in the practice of psychiatry—and perhaps in medicine in general—that makes suicide more likely.
I think both may be true. It is my impression that psychiatrists as a group tend to be thoughtful and passive individuals—as opposed to surgeons, who like to do something right now to fix a problem, and do not like wrestling with problems that get better, when they do get better, only after prolonged periods of time. There is evidence that people feel better when they are engaged actively in something—and feel worse when they are in repose. Thinking predisposes to feeling bad. (A depressing thought.) But these are generalizations only, and if they are true, they are certainly not true all the time.
What is true, undoubtedly, is that suicide is contagious. Psychiatrists, who deal all the time with patients who are thinking of suicide and sometimes actually committing suicide come to understand that suicide is an option in life. Witnessing a suicide, or reading about a celebrity who kills himself or herself, makes an individual more inclined to follow in those footsteps. When Marilyn Monroe died, there was a wave of suicides across the country. Also, psychiatrists—and doctors in general—have ready access to drugs, which are the usual means for suicide.
There are social and family problems that are peculiar to physicians, who work long hours and have great responsibilities, but I do not feel these matters weigh heavily in deciding whether or not to continue living.
Why a suicidal person chooses one method of dying over another is a subject for another time.(c) Fredric Neuman Follow Dr. Neuman's blog at fredricneumanmd.com/blog or visit Dr. Neuman's advice column at fredricneumanmd.com/blog/ask-dr-nruman-advice-column/