To the Editor: "A Physician’s Suicide," a clinical case conference by Herbert Hendin, M.D., et al. (1), is an excellent case study and opportunity to learn from one’s prior experience. It takes courage to present unsuccessful attempts to save a life. Many residents in training and psychiatrists beginning their careers have not had sufficient experience or conviction that psychodynamic psychotherapy, in combination with medication, is frequently the most effective and, in this case, potentially lifesaving treatment. While it is true that not all suicides are preventable, in my opinion, this one might have been.

The good news was that the patient sought help, his depression was recognized, and he stayed in treatment for 4 years. The astonishing tragedy was he did not get the help he needed. All the classic warning signs for suicide were present. He had a plan, he bought a gun, and he told his family he felt hopeless; he became increasingly agitated, he began self-medicating with benzodiazepines, and the treatment given was ineffective against his unremitting depression. He suffered two major losses and humiliation because of his wife’s affair and his inability to work. He improved just enough to have the energy to kill himself. Finally, he was an anesthesiologist who had access to and knowledge about lethal medications.

From a psychodynamic point of view, the greatest tragedy was his psychiatrist’s failure to deal with two factors: first, the patient’s resistance to exploring his anger and humiliation regarding his wife’s affair and, second, the psychiatrist’s countertransference. The surgical metaphor at the end of the discussion is a good one: "The patient may choose whether or not to have the operation but does not decide how the procedure is conducted, and the family is not invited into the operating room" (p. 2096). When this patient refused his doctor’s recommendation that meaningful psychotherapy was necessary, his refusal should have been explored and interpreted as resistance. This is a basic effective technique. Patients should not dictate treatment. Permitting his wife to sit in as a "consultant/caregiver" was a form of acting out (or "acting in") the therapy. It further demeaned him as if he were a child. Exploring the meaning of this and not permitting it to continue was essential. As long as it persisted, effective therapy was seriously compromised.

Countertransference errors further compounded the problem. That the patient was a physician probably contributed to his doctor’s countertransference "V.I.P." treatment. Prescribing another round of 18 ECT treatments after the initial course was unsuccessful not only reflected poor clinical judgment but may also have reflected the psychiatrist’s sense of hopelessness. When used appropriately, ECT can be lifesaving. In this case, it contributed to further hopelessness by the patient and the doctor. Finally, the psychiatrist’s collusion with his patient in failing to recognize the significance of his wife’s affair represented a major blind spot. This failure to address the patient’s intense unexpressed anger and humiliation reinforced the patient’s earlier feelings of inadequacy: "Dr. A normally showed little affect in discussing these topics" (p. 2094).

It is easy to be a Monday morning quarterback and criticize an event with an unsuccessful outcome. Instead, I commend the authors and the treating psychiatrist for presenting this case. The psychiatrist’s own comments after the suicide reflect his pain and self-doubt, but in reporting this case, he helped us learn a great deal.