A 48-year-old man comes to the office with his wife for follow-up of major depressive disorder. The patient has been taking sertraline for 2 years, and due to a recurrence of depression, he started bupropion and weekly cognitive behavioral therapy 3 weeks ago. Since then, his energy level has improved, and he is working on communicating more with his wife about his emotions. The patient has no suicidal ideation and is hopeful that he will feel better with continued treatment. A week later, his wife calls the office and states that her husband died by suicide a few days ago. She is tearful on the phone and says, "I thought that he was doing better. I don't understand how this happened." Which of the following is the most appropriate response?

Question

A 48-year-old man comes to the office with his wife for follow-up of major depressive disorder.  The patient has been taking sertraline for 2 years, and due to a recurrence of depression, he started bupropion and weekly cognitive behavioral therapy 3 weeks ago.  Since then, his energy level has improved, and he is working on communicating more with his wife about his emotions.  The patient has no suicidal ideation and is hopeful that he will feel better with continued treatment.  A week later, his wife calls the office and states that her husband died by suicide a few days ago.  She is tearful on the phone and says, "I thought that he was doing better.  I don't understand how this happened."  Which of the following is the most appropriate response?

Quizplus · Accepted Answer

The sudden, unexpected loss of a loved one produces intense, acute grief. When the cause of death is suicide, the emotional pain may be further complicated by a range of difficult emotions including guilt and anger as well as difficulty comprehending what happened. The need to make sense of the suicide may be especially intense when the family member perceives that the patient was doing better beforehand, as in this case. After a patient's death, disclosure of pertinent medical history (including psychiatric history) is permitted to a personal representative (eg, spouse, parent) under the Health Insurance Portability and Accountability Act (HIPAA). The immediate postsuicide response should acknowledge the bereaved individual's severe emotional distress and offer to answer questions related to clinical course and treatment that may help to make sense of what happened. This discussion should be conducted in an open-ended fashion, without making any assumptions about how the bereaved individual is feeling or what they want to know. It is particularly important to help alleviate any sense of inappropriate guilt that the bereaved individuals may be experiencing and make them aware of additional resources to assist with suicide bereavement if needed (eg, grief counseling, suicide bereavement support groups). (Choice A) Inquiring if the patient was taking his medication as prescribed inappropriately focuses the conversation on trying to find out specific reasons for the suicide rather than responding to the wife's acute, emotional distress in a compassionate manner that allows for open discussion. (Choice C) This response attributes the suicide to medication changes when it is unclear to what extent, if any, this was a contributing factor. (Choice D) This statement empathizes with the wife's shock but asks her to share details of her husband's death, which she may not feel comfortable doing. It is preferable to allow the wife to express her grief and ask any questions she may have about her husband's illness and treatment. (Choice E) Asking the wife if she noticed anything unusual in the week leading up to the suicide may have the unintended consequence of making her feel that she missed signs and is in some way to blame. Educational objective: Responding to bereaved individuals following a suicide requires a compassionate and open-ended approach. Clinicians should acknowledge the bereaved individual's emotional distress and offer to answer any questions pertaining to clinical course and treatment that may help to make sense of what happened.

A 48-Year-Old Man Comes to the Office with His Wife