An overheard conversation led Alys Cole-King to discover that the stigma of suicide can prevent patients from expressing their feelings and doctors from asking about them. Her blog marks World Suicide Prevention Day, which falls on September 10 every year.
‘Her carbon monoxide levels are below the treatment line so she can go home now...’ Twenty years later I still recall these words and remember the tense and sick feeling you get when you experience a ‘near miss’ with a patient.
It was mid afternoon one Saturday in early 1993 and I was the duty psychiatrist on the ‘post take overdose round’ as we called it then. I had just assessed my seventh patient that day and felt it was way past lunch time. I was starving and running late for a pile of work at the local DGH which had been steadily building up since early that morning.
When I overheard the medical SHO say these words to his registrar I paused but insisted: ’I know you think there’s no need but I really want to see her — if only for my peace of mind, and it won’t take long’.
I entered the room and introduced myself to an immaculately presented middle-aged lady. She seemed a little flat in spirits, but with impeccable manners she invited me to sit down. She then tried to reassure me there was no need for me to talk to her as she was fine, it was all a big mistake and she needed to get home.
I could see how my colleagues had felt it difficult to break through the stigma of asking if she had attempted to take her life. She looked like she could have been my mother, an aunt, a senior colleague, a confident professional. Not someone who had just made an extremely serious attempt to end her life.
That day I learnt an early lesson about stigma. One dictionary defines it as a ‘mark of shame or discredit, an identifying mark or characteristic’. I could see how the stigma of suicide had prevented the patient from sharing their thoughts and to encourage the medical team to collude with the story that everything was fine.
Luckily I had overheard the conversation and I was prepared to scratch the surface of the polished veneer. Initially all my questions were met with polite, non-committal responses. But realising that I was going to be persistent, she started to open up, initially just a chink, by admitting that her sleep ‘may not be what it was’.
Then gradually with my gentle questioning it all came out. She was extremely depressed with a full house of symptoms of depression. She said that for the past six months she had felt her life was not worth living, but was terrified to tell her husband (‘a very busy businessman’) or her son, a surgeon in London. She had tried to end her life four times in the previous few weeks, each time engaging in progressively more dangerous attempts. This latest attempt was a determined effort to end her life.
I felt a chill and an overwhelming sense of relief that she had found the courage to tell me everything. She reluctantly agreed to confide in her family and I was delighted when she agreed to an informal in-patient stay. She subsequently made a complete and speedy recovery.
I still get jittery when I think how close it came to her not being seen, going home and carrying out what she said she had been intending to do when she got there. I wouldn’t have asked to see her if I hadn’t by chance overheard that conversation on the ward that day about her carbon monoxide levels, and I might not have stood up to the registrar.
Stigma kills. I’m convinced that both those medical doctors didn’t want to refer her to me because of the stigma of a suicide attempt. But anyone can experience suicidal thoughts. It’s not a ‘them and us’ issue. Tackling stigma and raising awareness is a vital step in saving lives. Suicide prevention is a patient safety issue and it is everyone’s business. There is more information on our website regarding the Connecting with People campaign, including resources for patients and professionals.
Alys Cole-King is a consultant liaison psychiatrist in north Wales, Royal College of Psychiatrists spokesperson for suicide and self-harm, and director and co-founder of Connecting with People, a not-for-profit organisation that provides free online resources and innovative bite-size training in building emotional resilience, mental health awareness and suicide awareness. Details in this blog have been changed to protect patient confidentiality.
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I wish that all hospital psych staff were like yourself.
Last week I parked my car in a lay by and tried to end my life - obviously failed but I ended up in A&E. Brief chat with someone and although still groggy from the pills was discharged. No one really wanted to listen why. So I then staggered up to the top of the conveniently situated car park and sitting on the ledge considered whether it was high enough. I was rather violently grabbed from behind by 2 police officers soon after. Again no questions as to why. Ended up walking home 5 miles too tired to do anything other than blot the rest of the day out with sleeping pills.
Your description of the lady in A&E could almost be me. It's time that professionals realise that suicidal feelings can hit anyone even them perhaps one day and then see how they feel when they are judged and dismissed. Who do you talk to then?
Firstly I am so sorry that you are having such a tough time and please know that there is always hope. This is the very reason that I and colleagues developed a range of practical and compassionate self-help resources on behalf of the Royal College of Psychiatrists - available to anyone in need of advice and support. They share hope, promote appropriate self-help and inform people regarding useful strategies, how to create a ‘safety plan’ and how they can access help and support.
• Feeling on the edge helping you get through it - for people in distress attending the Emergency Department following self harm or with suicidal thoughts
• Feeling overwhelmed and staying safe and for anybody struggling to cope when bad things happen in their life
• U Can Cope originally designed to help younger people develop resilience and cope with any current/future difficulties in their life. Just as helpful for adults of all ages!
The resources also include links to all available national support
Secondly I also wanted you to know that Connecting with People is a ‘not-for-profit’ organisation and we deliver training in all sectors including healthcare. There are currently trainers delivering free in-house #CWP suicide awareness sessions all over the UK.
Thanks for writing that Alys. Avoidance for whatever reason can go on to create a disastrous situation where the person feeling suicidal withdraws even more into themselves. For many it can come down to lack of training, confidence in asking for fear of saying something wrong, embarrassment, awkwardness, lack of belief in the seriousness of the situation and even the "attention seeking" effect. I believe that those who are naturally compassionate people can and do save lives by making that judgement call like you did.
One doctor is better than another doctor because he or she asks more questions as the adage has it.
Confidentiality may be overvalued in certain contexts, and in our society is become to some extent the refuge of scoundrels.
No giudelines can eliminate the need for care, assiduous attention to detail, and experience.
I actually have had at least one complaint against me from a mother who presented her child but in fact she was the true patient and rejected my advice that she should see her GP or a psychiatrist for her depression. A&E is full of pitfalls.
I'm currently experiencing discrimination and the effects of stigma. I'm a med student and failed by year at uni due to my depression and suicidal thoughts. The school have said I need to go to fitness to practice committee and have said I can repeat my year as long as I don't get unwell again. Far too much pressure there, but it's all I want to do! I dream of being a psychiatrist and helping people as you have helped that lady. I know I can do it, but I don't feel supported by my uni.
Regarding Kate's comments, I think it is completely over the top to send her to a fitness to practise committee. She is a medical student, not a practising doctor. What has happened to common sense and humanity? The ruling that she can repeat her year only if she doesn't get unwell again is outrageous. Suppose she had had treatment for cancer. Would anyone have said that she could repeat the year only if the cancer did not come back?
I think the university authorities need to be asked about the research evidence base for their treatment of Kate. Of course, they won't find any evidence base as there will be no randomised controlled trials of treating medical students with humanity and common sense compared with treating them with neither.
Please feel free, Kate, to use my comments as you wish. There is a great need for people like yourself , who really care, to become psychiatrists. The patients very quickly spot those doctors who really care and are not just going through the motions or ticking boxes on a protocol. I believe that such doctors can prevent suicides, but it can't be proved because there are no randomised controlled trials (and never will be any)comparing treatment by psychiatric services with no psychiatric treatment at all.
Best wishes for the future. I hope you have every success.
(Dr Mark Hughson, MD, FRCPsych, Consultant Psychiatrist)
An extremely well written and salutory take from A&E, also salutory for us GPs - we can go through the motions of asking the required questions, or we can talk to the patient and listen to them.
Thank you for this article, I wish more doctors would make the extra effort to dig a little deeper with patients. I hope I will remember this if I find myself in a similar situation with a patient in the future
Kate I am so sorry to hear that you are having to go through this without the support of your university. I feel it is very unfair that you have been burdened with the pressure of trying to get better quickly. I am a medical student myself and I know fellow students who have struggled with depression and suicidal thoughts too, and have had to retake or suspend for a while.I really believe that you will be a better Dr one day because of it. I can't even imagine how hard it must be for you but I know you can do it too and you will make an excellent psychiatrist one day,if that's what you want.
It would have been helpful I think if someone had mentioned The Samaritans .
This 24hr phone,Email,SMS,and text service is available to anyone who is in crisis or thinking of suicide.We will listen and provide a safe non-judgemental, confidential environment in which to explore people's feelings and discuss their options anonymously .
I agree with the comments about Kate having experiences and strengths from her experience that will help patients. I was quite moved by hearing Jack Straw talking about his depression on Radio 4, also I find Stephen Fry quite enlightening. I hope you have support from some quarters Kate, and also advocates (NUS / BMA/ MIND- you may know better than me - I wish you all the best. Have had my experience of depression, it gave me insights that I hope have helped others.
Kate, I can't believe how your university are treating you.
I had depression as a medical student and my GP at the time wrote to my university and I had some time off. There was no question of my fitness to practice. Thanks to their support I made a gradual recovery and had no further problems.
I have no doubt that my experience has made me a far better, empathic and understanding Dr. -I can really understand how bad it feels to be lost in the darkness of depression, I was there! Good luck with everything Kate and keep believing in yourself, you are right to think this treatment seems unreasonable.
This article is really useful and I will look at the resources and signpost patients to them. Thank you
Thank you so much for your comments. I do believe I'll be a good doctor if only I can get to that point.
Mark - thank you so much for your kindness, I do hope I'll make it to become a passionate psychiatrist. I'm already incredibly passionate about psychiatry and getting rid of the stigma and discrimination that surrounds mental illness. I sincerely hope my medical school starts supporting me in this rather than putting obstacles in my way.
Thank you so much for all your comments although some, especially Kate's are hard to read...I sincerely hope you get the support you need.
You may wish to see the new #CwP 3min film on tackling the stigma of suicidal thoughts connectingwithpeople.org/wspd
Please also see the 20 min film released on WSPD in 2012 called U Can Cope. It features three inspirational people who bravely share how they felt like live was not worth living, became suicidal and with support managed to 'get through' and now live happy and fulfilling lives. The film has 3 main messages
There is always hope
There is always help & support
You can be supported through suicidal feelings and recover fully
The film and self help resources - which include information and links for many
national support organisations mentioned in the comments above can be found via connectingwithpeople.org/ucancope
You may also wish to see our blog which includes the background to this approach and a summary & abstracts for 3 new APT articles. One of them is the story of Kevin Hines a courageous, deeply poignant and ultimately inspirational story of survival.....highly recommended reading for all - an incredible account proving that there is always hope and that no one is ever beyond help. The blog is at: www.connectingwithpeople.org/Blogroll
Kate, I was ill through university, and had to fight through my foundation years to prove that living with a mental illness did not make me an unfit doctor. I was lucky enough to have a supportive undergrad tutor - I believe that our experiences will make us better doctors and give us an insight into our patients which our collegues may not have.
I don't know if there is a way of doing this, but should you ever wish to contact me to rant, share experiences, or if I can offer you some 'peer support' in any way, I'd be really happy to do that.