To the Editor: In their recent case conference, Dr. Hendin and colleagues discussed the suicide of Dr. A, a 51-year-old married staff anesthesiologist. The authors made several important points regarding the difficulty a physician, in this case a psychiatrist, has in providing treatment to other physicians. They observed that the treating psychiatrist might have seen the patient in individual treatment rather than in couples therapy, might have explored marital difficulties, and might have placed emphasis on psychotherapy rather than on pharmacotherapy.

All of these points made by the authors make sense, but in a clinical pathological conference, it seems that the authors shied away from discussing the central issue. The anesthesiologist’s depression was precipitated when he learned that his wife was having an extramarital affair. Although the affair allegedly ended, the core issue and last straw for the patient was his wife’s affair. The authors could have used this precipitant as the starting point for a discussion of therapy. One wonders what this extramarital affair meant to the patient.

The job of the psychiatrist should have been to explore, most likely in individual therapy, such issues as whether the anesthesiologist felt he was a failure in his loving relationship with his wife, whether he was sexually satisfied, whether the affair threatened his masculinity, whether he was able to share intimate feeling with his wife, and whether he thought his wife was unhappy with the marriage and, if so, why. A detailed exploration of the precipitant would have allowed the patient to acknowledge what was most painful. It would have permitted an alliance to be formed between the patient and therapist and allowed release of forbidden thoughts, wishes, and fantasies.

Once the patient began to acknowledge his feelings, the psychiatrist could have helped him put the feelings in some perspective. This might have involved the patient’s looking at his strengths and limitations and at his relationships with others. Long-standing personality issues would become salient. The therapeutic goal would be to help the patient come to terms with both his needs and those of his wife and others.

A clinical pathological conference is an opportunity to look at what might have been done differently. The goal of individual work would have been to help the patient acknowledge, bear, and put in perspective what was most painful. This would have involved the psychiatrist being capable of tolerating these affects. If this work had been attempted as couples therapy, it would have been necessary for the wife to agree to therapy not just to serve as a helper. This would have meant that both members of the couple would have had to share intimate and painful details, a difficult but rewarding task. The precipitants would have needed to be discussed with both present.

Although the authors made good points about the patient’s history, work experience, etc., in my opinion, they failed to begin with the precipitant and work toward understanding the nature of the pathology. If one begins with the precipitating event, a patient often will see that there are alternatives and hope. Patients will begin to trust and feel acceptable and accepted.

These comments are not meant to say that suicide could have been prevented but rather how one could have looked at alternative approaches and considered how a different approach just might have changed the outcome. A dynamic treatment perspective in this case might have opened up the possibility for the patient to change his mind.