Suicidal Ideation: What to do when going towards the cliff’s edge

Authors: Loice  Swisher, MD (Drexel University College of Medicine and Vice Chair Resilience Committee) and Ramin Tabatabai, MD (LAC + USC Medical Center) submitted on behalf of the Resilience Committee in recognition of the first National Physician Suicide Awareness Day: September 17, 2018

Depression incidence in 740 interns increased from 4% to 27% in the first 3 months of training, while thoughts of death rose 370%.

Sen, S. et al., Archives of General Psychiatry 2010


Dear Program Director,

I’m concerned about xxxx.  He has been making comments about killing himself and he seems to mean it.  I’m not sure what to do but I thought you should know.   Please call me if you want to know any more.


Your Resident


It is quite possible that these emails, phone calls or personal interactions will become more common.  The 2017 ACGME Wellbeing Common Program Requirement  VI.C.1.e).(1)   ‘encourages residents and faculty members to alert the program director or other designated personnel or programs when they are concerned that another resident, fellow, or faculty member may be displaying signs of burnout, depression, substance abuse, suicidal ideation, or potential for violence.’    However, few in program leadership have been given instruction or tools to know what to do with this beyond meeting with the resident and sending them to the employee assistance program (EAP).

Few residents that program leadership meet with will be in active crisis with an imminent threat of attempt.  Many residents will benefit from additional help, however, there is often a delay of hours to days before the resident can meet with these people.  It is in that gap that program leadership can provide a bridge of support for the potentially suicidal resident.  The most important thing to remember is that isolation is devastating.   The feeling of being ‘sent away’ or being ‘too scary to deal with’ can be crushing.   This is the time to say, ‘You are not alone.  I am here for you.   We are going to do this together.’

Suicidality is like anemia.  There is way more than one cause and it can be multifactorial.   In June 2018, the CDC released findings that only half of the people who died by suicide had known mental health issues.  The other half suffered from life stresses including job, legal, money, housing, physical health or substance abuse issues.  Regardless of the suicidal ideation etiology or a personal lack of knowledge or comfort with suicide, here is an initial  5-3-1 basic plan program leadership can use to provide first steps support for a suicidal resident not in active crisis.  Provide the resident:

  • Five Rules to Live By
  • A Three Step Suicidal Safety Plan
  • One additional resource (at least)


Five Rules to Live By:

  1. Sleep at least 8 hours in a consecutive block before making any permanent decisions.

In at-risk individuals, sleep disturbance and disruption heightens the risk for suicidal ideation.  The relationship between disturbed sleep and suicidal ideation has been known for some time.  In fact, at one time suicidal individuals were admitted to the hospital for ‘sleep therapy’.  In 2012, Pigeon et al published a meta-analysis that showed “persistent sleep disturbance was significantly associated with an increased relative risk for suicidal ideation, suicide attempts and suicide and that this increased risk was not due to depression.”


  1. There is no safety without sobriety.

Do not make a suicidal decision while intoxicated with any substance.   When one is suicidal, intoxicants rarely if ever help the situations.  To keep one safe, do not use mind-altering substances when one is depressed or suicidal as it might drive one further down that path.


  1. You don’t have to catch that train (of thought).

Just like you don’t have to jump on every train that comes by, one doesn’t have to pursue a suicidal line of thinking whenever a suicidal thought enters one’s mind.   The suicidal still have free will to choose what path of thinking that they will pursue.   With attentive practice one can let those suicidal thoughts go, develop alternate pathways of thinking/coping and can find practical distractions allowing the suicidal thoughts to pass.


  1. Give it 3 days.

Big decisions- especially ones that may be irrevocable- deserve time.   Unfortunately, some studies have shown in the general population that about half the people go from thoughts to attempt in 10 minutes or less.    Even more unfortunate is that the phase of acute suicidal crisis usually fades in hours.   In review of people who were stopped from jumping from the Golden Gate Bridge, 90% never attempted suicide again.  In addition, one of the few survivors of a Golden Gate Bridge jump (Kevin Hines) says he knew “immediately when his hand left the rail he made the wrong decision.”


  1. Call someone, you might be a bug in a cup.

Call someone.   If you think that they can talk you out of suicide then there likely is a part of you that wants to live and deserves to be heard.


Often people with suicidal ideation essentially develop tunnel vision and are no longer able to see any other viable option but suicide.   Dr. Paul Quinnett, a suicidologist, describes this as being like a bug at the bottom of a tea cup.   The suicidal can’t see the outside and go round and round in their thinking.   One needs someone else to tip the cup so that perhaps the suicidal can see more options and find a different way out.


A Three Step Personal Suicidal Safety Plan

Those with suicidal ideation rarely want to die.  Instead, they have not found a better way to cope with the situation or pain that they are in.  The suicidal almost always have a more rational side which can be ‘put in charge’ and can work on developing a plan.


Joiner’s theory of suicide identifies three factors that are usually required for suicide.  A personal safety plan can address each of these three.   There are free apps (such as Virtual Hope Box or My3) one can have on one’s phone for this.    You can start a resident in developing their own safety plan to take the place of their suicide plan or thoughts.


  1. Thwarted Belongingness– This is a sense of isolation. Develop strategies to remind oneself of those that are important and strengthen connections.
    1. Identify three people to call when you feel down and alone.
    2. Have an album of pictures on your phone to remind you that you are not alone.
    3. Keep voice mails/messages from people you love and are important to you on your phone.
  2. Perceived Burdensomeness– This is a sense of failure. Develop reminders of past successes and futures dreams.
    1. Make a list of successes.
    2. Make a positive personal mantra.
    3. At a good time write a letter to yourself about why you wanted to be a doctor.
    4. Make a personal list/archive of cases where you made a difference.
    5. Make a list of your strengths.
  3. Capability of Suicide- Decrease access to means.  For example:
    1. If one has guns in the house, make it more difficult for impulsive decision. Have lock box.  Put the ammunition further away from the gun.  Place a reminder on or by the gun to call someone.
    2. Remove as much medication from the house as possible.
    3. If one has a propensity towards jumping, avoid higher levels of building (or avoid facing windows if one must go there) and attempt to avoid bridges while driving. Park on lower levels of parking garages.


One Additional Resource

The resident may have no idea what resources are available, how to access them or if they would be useful.   Providing options can be helpful.  Transparency is important.  Remember that not one shoe fits all.  Some may be dealing with depression while others may have professional development stresses and others will have life crises.  Still others will prefer to do things on their own and these resident can be made aware of self-help resources.


  • EAP– Employee Assistance Program: This is available at most institutions and should provide a small number of free counseling sessions.
  • Other local resources: In light of the ACGME well-being CPRs, many institutions have developed internal mental health resources for residents in crisis.  One’s GME office should be able to provide any listing of available local resources.
  • Personal insurance: It is possible to use personal insurance to access counseling services.  If a resident has not had to uses medical insurance before, human resources may be able to provide guidance.
  • Crisis hotlines: The national crisis hotline and text line are available to all.

Crisis hotline: 1-800-273-8255 (TALK)

  • Second Victim Syndrome/Peer to Peer Support: Some residents will be struggling with bad patient outcomes, medical errors, litigation or professional development issues.  These situations often are better handled with peers and physician colleagues who truly understand the complexity and depth of these experiences
  • Program Leadership: Program leadership can be especially effective in decreasing the sense of isolation, explaining additional resources and being a barometer on what is normal versus unusual circumstances in residency.  In addition, program leadership is critical to establish accommodations when needed.
  • Attention to sleep disturbance: One should not underestimate the impact of sleep disturbance, sleep deprivation and insomnia on suicidality. Residency is prone to sleep issues whether this is with call or rotating shifts.
  • Other supports: Some residents will be dealing with life stressors that may benefit from outside support.  For example, a resident is dealing with a parent with Alzheimer disease or a child with leukemia may benefit from connecting with others who are dealing with the same thing.
  • Self-help: Yes, a resident can benefit from bibliotherapy.  There is self- help (books, websites, apps) for the suicidal- to prevent going down that path.   There are many sites but one that has much at one location is


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