Dr Pooja Saini is a researcher and Chartered Psychologist at the University of Liverpool and currently involved in suicide prevention research. In this blog post, she will share her research and describe what role GPs and Primary Care providers can play in suicide prevention. Additionally, her research includes the opposite effect: the effect patient suicide has on GPs. 

Suicide is a major health problem. In England, around 5,000 people end their own lives annually – that is one death every two hours and at least ten times that number of attempts, according to the Office for National Statistics. Suicide is a tragedy that is life altering for those bereaved and can be an upsetting event for the community and local services involved. Our previous research demonstrated the:

• Majority of suicide patients (over 90%) have consulted their General Practitioner (GP) shortly before death¹;
• Variation in risk assessment between professional groups and a lack of suicide risk assessment training in primary care²;
• Dilemma GPs faced when managing patients who were non-adherent to treatment³);
• Very real struggles experienced by GPs in their attempts to make sense of patient communication of suicidality, to get patients the treatment they need and to respect patient autonomy while fulfilling their professional responsibilities⁴;
• Concerns GPs expressed about the quality of primary care mental health service provision and difficulties with access to secondary mental health services⁵;
• Need for formal support and guidelines within primary care for GPs following patient suicide⁶.

The role of the GP in patient’s suicide

Although patient suicide is uncommon in a GP’s career – one in every 3-7 years per GP and six in every ten years per GP practice⁷⁸ – it is important to place appropriate emphasis on the effects of patient suicide on GPs. The role of the GP in this context includes suicide treatment and prescription, prevention, professional attendance at the scene of a suicide, comforting the bereaved, and the critical incident review following a patient suicide. GPs support requirements, such as access to formal support in counselling, debriefs following significant events, or helplines may differ following a patient’s death by suicide compared to death from other causes related to physical ill health, because GPs may see suicide patient deaths as preventable. 

Practices are increasingly exploring the use of critical incident reviews which encompasses a quality improvement intervention involving a consulting psychiatrist review of each case in primary care following patient suicides. The purpose of the reviews was to determine whether useful lessons could be learnt about future clinical practice. The reported findings are that GPs identified a tremendous sense of guilt, as well as a fear of being blamed after a patient’s suicide and shared a perception of being increasingly expected to prevent events outside of their control. GPs reported a fear of being held accountable for their own decisions when managing patients at risk in primary care⁹. Similar findings were reported previously regarding GPs guilt following patient suicides¹⁰. Studies reporting on the effects of suicides on GPs are sparse and more research is needed.

Caring for our doctors: implementation of formal support systems

Our findings suggest that the majority of GPs are affected by patient suicide. Those that were more affected by patient suicides tended to have fewer years in practice. On the other hand, many GPs who were not affected, reported that they have accepted the psychological toll of patient suicide as a part of their profession. Most GPs we surveyed sought informal support from their peers and colleagues. An interesting finding was the apparent lack of formal support systems and the varied responses from GPs about what encompasses support. This opens up an area for concern where formal support mechanisms may need to be put in place – or where they are available, to be more visible. Although GPs can also make use of generic medical support mechanisms for formal assistance (e.g. British Medical Association and the National Counselling Service for sick doctor), the extent to which specific services are accessible to GPs working in primary care seems to be poor.

In view of the close involvement of GPs in the lives of their patients and families, procedures should be developed in primary care to ensure the availability of information for those GPs who may require additional formal support following the death of a patient by suicide. The recent structure of Clinical Commissioning Groups (CCG) and the rapid development of GP postgraduate education through the introduction of Practice Professional Development Plans provide an excellent opportunity for change. Critical Event Review combined with meaningful peer support is essential. It should lead to greater mental health protection for primary care staff who are as likely as doctors to experience psychological injury as a result of a patient’s suicide.

About the author:

Dr Pooja Saini is a researcher and Chartered Psychologist at the University of Liverpool, working as the Knowledge Exchange Theme Manager for the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC NWC), and currently presenting suicide prevention research to GPs and Primary Care providers across the North West Coast. For over 10 years, she has been interested in how the health service could be improved to meet the needs of individuals who are at risk of dying by suicide and support for people bereaved by suicide. This includes the wellbeing of GPs when patients under their care die by suicide and improving crisis facilities for patients who may be in crisis. You can contact her by email at pooja.saini[at]liverpool.ac.uk.

bibliographical references

1. Pearson A, Saini P, Da Cruz D, et al. (2009). Primary care contact prior to suicide in individuals with mental illness. British Journal of General Practice, 59(568), 825-32 [↩]
2. Saini, P., While, D., Windfuhr K., Chantler K., and Kapur, N. (2014). Assessment and management of suicide risk in primary care. Crisis, 35 (6), 415-25. [↩]
3. Saini, P., Chantler K., and Kapur, N. (2016). GPs’ views and perspectives on patient non-adherence to treatment in primary care prior to suicide. Journal of Mental Health (in press [↩]
4. Saini, P., Chantler K., and Kapur, N. (2015). GPs’ perspectives on primary care consultations for suicidal patients. Health and Social Care in the Community. doi: 10.1111/hsc.12198 [↩]
5. Saini, P., Windfuhr, K., Pearson, A., et al. (2010). General Practitioners Views on Service Availability. BMC Research Notes, 3: 246. [↩]
6. Saini et al. 2015, op.cit. [↩]
7. Matthews K., Milne S., Ashcroft G.W. (1994) Role of doctors in the prevention of suicide: the final consultation. British Journal of General Practice, 44, 345-348. [↩]
8. NCISH [National Confidential Inquiry into Suicide and Homicide by People with Mental Illness] (2014). Suicide in primary care in England: 2002-2011. Manchester: University of Manchester. [↩]
9. Kendall K, Wiles R. (2010) Resisting blame and managing emotion in general practice: The case of patient suicide. Social Science & Medicine, 70 (11), 1714–20. [↩]
10. Halligan P & Corcoran P. (2001) The impact of patient suicide on rural general practitioners. British Journal of General Practice, 51, 295–296. [↩]