By Courtney Wagner, MD (PGY-3)

Above: Dr. Courtney Wagner, PGY-3

Frequency illusion is a phenomenon in which after first noticing something, you start to see it everywhere. After losing my father to suicide during my intern year, this happened to me with the semicolon tattoo. In grammar, a semicolon is used when an author could have chosen to end the sentence but did not. For people struggling with mental health, this has become a symbol for when somebody could have chosen to end their life but did not.

After my father passed, I knew certain things would be hard, such as holidays or missing our frequent conversations and shared jokes - but working in healthcare came with additional, unexpected difficulties. Upon first returning to work shortly after his passing, I started on a string of night shifts in the MICU, where one is particularly likely to encounter death. My chest would tighten on call days when our team accepted a patient with suicidal ideation or after an attempt. Fortunately, my upper level and co-intern were understanding, rearranging assignments during the first few months.

One night, however, a patient close to my father's age died, and I had to speak with his daughter. I was confronted with the complex feeling of being both deeply saddened for their family, while still processing my own grief. A few weeks later, a healthcare worker died by suicide after jumping from the 6th avenue parking deck. Shortly thereafter I sat in a room with fellow residents, unknowingly joked critiquing suicide plans. Yet with the support of family, close friends, and program leadership, I survived that first year.

I reflected on how little we are taught about suicide throughout our medical training. For exams, we learn about epidemiology, risk factors, evaluating, and then hospitalizing patients with suicidal ideation; but it stops there. In practice, our medical assistants in clinic screen for suicide alongside a laundry list of questions about their chief complaint or pain level. Even positive screens can get lost in the fray and an opportunity to intervene is missed.

As primary providers, we have time constraints that make it not only difficulty to detect, but also difficult to appropriately treat mental health or substance abuse disorders. I wanted to change that in my own practice. Reading more about the topic and listening to the lived experiences of suicide survivors became therapeutic to me after I lost my father. But it was also heartbreaking to learn that my father was one of 47,500 people who died by suicide in 2019, making this the 10th leading cause of death in the United States1. Expand that out to the 1.4 million people who attempted, 3.5 million who made a plan, and 12 million who seriously thought about suicide in that same year, and the numbers are overwhelming. We have yet to fully realize the effect the pandemic has had on these annual numbers, and it may be years before the full consequences on our mental health are known.

In the past 10 years, our rates of suicide have increased by 33%1. Sadly, many of these same people were in contact with their primary provider in the final month before their death and more than a third of suicide victims used alcohol prior to death.2 Both applied to my father.

At first these statistics were almost suffocating. Millions of people suffered so much they felt at some point their only choice was death. Suicide—whether attempted or completed—has a ripple effect on family and friends that is unlike many other diseases. It's grief with an asterisk, leaving those behind with a mixture of anger, guilt, confusion, and sadness about how the tragedy could have been prevented. Listening to survivors share their stories helped me learn that suicide isn't selfish, weak, or punitive. Certain parts of the brain change in the acute suicidal moment and the person feels they have no choice3. However, many survivors immediately regretted their decision. Creating barriers to access, such as freezing bullets in ice cubes or removing a gun altogether, can help the suicidal moment pass so that the person can go on to live and seek help. Fortunately, around 90% of those who attempt and survive do not die from a subsequent attempt4. Suicide prevention is complex and multifactorial, and I do not pretend to have the answers after my personal experience. I will, however, end this with a few pieces of advice:

• Read or listen to stories. Try the podcasts Suicide Note or Terrible, Thanks for Asking. The American Foundation for Suicide Prevention also has a good compilation of short videos.

• Wording matters while discussing mental health disorders. Saying "committed suicide" or "killed themselves" has a more negative implication than "dying by suicide."

• Realize you never know who has lost somebody to suicide or is struggling themselves, even saying things like "Ugh, I want to kill myself" or placing a finger gun to your head can be jarring.

• If you are concerned about a friend or patient, don't debate the value of life or minimize problems. Make it a priority to reach out, listen without judgment, and offer to get them connected to resources, such as counseling, support groups, and mental health providers.

In the spirit of the semicolon, we can stop learning about mental health issues after passing board exams, or we can choose to continue. This is true not only for our patients but also for ourselves. Realizing that everybody struggles at some point, from the patient we are admitting to the intern we are supervising, is possibly just as important as learning the diagnostic criteria and treatment options.

1. Suicide Prevention Fast Facts. (2021, March 23). Retrieved from https://www.cdc.gov/suicide/facts/index.html

2. Stene-Larsen K, Reneflot A. Contact with primary and mental health care prior to suicide: A systematic review of the literature from 2000 to 2017. Scan J Public Health. 2019 Feb;47(1):9-17. doi: 10.1177/1403494817746274. Epub 2017 Dec 5. PMID: 29207932.

3. van Heeringen K, Mann JJ. The neurobiology of suicide. Lancet Psychiatry. 2014 Jun;1(1):63-72. doi: 10.1016/S2215-0366(14)70220-2. Epub 2014 Jun 4. PMID: 26360403.

4. Owens D, Horrocks J, and House A. Fatal and non-fatal repetition of self-harm: systematic review. British Journal of Psychiatry. 2002;181:193-199.