2.1 Study design

A cross-sectional survey was conducted among psychiatrists practicing in private, university, and government settings across Malaysia. The study aimed to examine the personal and professional impact of patient suicide on psychiatrists in Malaysia. Data collection began in 1^st December 2023 and concluded in 30^th April 2024.

2.2 Participants and sampling

At the time of the study, Malaysia had approximately 600 practising psychiatrists. Snowball and convenience sampling methods were used for participant recruitment. Psychiatrists were invited through professional networks, institutional mailing lists, and direct referrals from colleagues. The survey invitation was disseminated through a national psychiatric association WhatsApp group comprising approximately 323 members and was also sent to 30 Heads of Psychiatry Departments in Malaysian universities for further distribution. As convenience and snowball sampling methods were employed and the survey link could be redistributed beyond the original recipients, the total number of psychiatrists who received the invitation could not be determined. Therefore, a formal response rate could not be calculated. Eligible qualified participants included psychiatrists currently practicing in private hospitals, university hospitals, and government healthcare facilities in Malaysia. The study did not include psychiatry trainees.

2.3 Data collection

Data were collected using a self-administered online questionnaire, which was adapted from the survey used in a previous study examining the impact of patient suicide on clinicians [3]. The questionnaire covered several domains such as sociodemographic information (e.g., age, gender, years of practice, workplace setting), details of the suicide event, personal and professional impact, helpful and unhelpful actions, resources and coping mechanisms. Several modifications were made to improve relevance to the Malaysian context, including changes to demographic and professional characteristics, removal of UK-specific organisational and medico-legal items, and inclusion of culturally relevant support options. A pilot test was conducted to evaluate the survey within the Malaysian context. The evaluation confirmed the instrument’s feasibility, clarity, and cultural relevance, with only minimal modifications required. The questionnaire was hosted on an online survey platform and distributed via email and professional groups. The questionnaire was administered in English.

2.4 Ethical considerations

This study was approved by Medical Research and Ethics Committee (MREC), Ministry of Health Malaysia (MOH) (NMRR ID-24–00228-IJD) and the Universiti Kebangsaan Malaysia Research Ethics Committee (FF-2023–288). All procedures were conducted in accordance with the ethical standards according to the principles of the Declaration of Helsinki. Participation in the study was voluntary. Prior to participation, all potential participants were provided with a detailed participant information sheet outlining the purpose of the study, procedures involved, potential risks and benefits, and their rights as participants. Participants were required to indicate informed consent electronically before accessing and completing the questionnaire. Only participants who provided informed consent were able to proceed with the survey. To protect participant privacy and confidentiality, all responses were collected anonymously. No personal data that could identify participants was collected or stored, and no personally identifiable information was obtained.

2.5 Data analysis

Quantitative data was analyzed using descriptive statistics using SPSS. Free-text responses were analysed using an inductive thematic grouping approach. Two authors (MHAL and NIAT) independently reviewed the responses and identified preliminary codes and themes. The emerging themes were subsequently discussed and refined through consensus until agreement was reached. The final themes were used to summarise psychiatrists’ experiences of patient suicide, its impact on clinical practice, and perceived support needs.

3.1 Participant characteristics

A total of 120 psychiatrists practicing across Malaysia participated in the study. The median age of respondents was 38 years (IQR 36.8–42.3 years), and the median duration of psychiatric practice was 3 years (IQR 1–10 years). Among the respondents, 44.2% were male, while 55.8% were female. In terms of ethnicity, the majority identified as Malay (60%), followed by Chinese (25%), Indian (12.5%), Punjabi (1.7%), and Native (0.8%). The majority were employed in government hospitals (56.7%), while others worked in academic institutions (22.5%) and private practice (27.5%). The majority of respondents worked in both outpatient and inpatient settings (63.3%), while (25.8%) only worked in outpatient settings.

Seventy-nine percent (n = 95) had experienced at least one patient suicide. Over half (53.7%) reported that the most impactful suicide occurred within their first five years of practice with 17.9% of these happening within the first year, often in community (51.6%) or clinical (48.4%) settings

3.2 Experience of psychiatrists following patient suicide

3.2.2 Effects on clinical practice.

Regarding the impact on clinical practice, 56.8% of participants reported a detrimental effect on their confidence. Among those affected, the duration of this impact varied; for 31.6% (N = 30), it lasted between one and four weeks, while 18.9% (N = 18) experienced it for one to six months. A smaller proportion, 2.1% (N = 2), reported the effect persisting for six months to two years, and 4.2% (N = 4) indicated that it was ongoing. Psychiatrists who reported a detrimental effect on their clinical confidence had significantly higher emotional impact scores than those who did not report such effects (p < 0.001). Additionally, more women (N = 34) than men (N = 20) reported a detrimental effect on their clinical confidence following a patient suicide, though the difference was not statistically significant.

Among the 120 participants, 95 (79%) of them who had experienced a patient suicide provided free-text responses. The free-text responses indicate that many psychiatrists experienced a significant impact on their clinical practice. Table 1 summarises the themes describing how psychiatrists’ clinical practice was affected.

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Table 1. Effect of client suicide on clinical duties.

https://doi.org/10.1371/journal.pone.0356052.t001

Career-related impacts following a patient’s suicide were less common among respondents. A small proportion (8.4%, N = 8) considered changing their career due to the experience, while an even smaller group (4.2%, N = 4) contemplated relocating their practice.

3.3 Support following patient suicide

About 16.8% of psychiatrists accessed external support outside of work, such as from a spouse or close friends. Those who received external support were associated with a significantly greater impact on their emotional well-being following the loss compared to those who did not (p = 0.011). The free-text responses on helpful and unhelpful support received after the loss are summarized in themes and presented in Table 2.

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Table 2. Helpful and unhelpful support received after the loss.

https://doi.org/10.1371/journal.pone.0356052.t002

Respondents were asked about the types of support they would want following a patient suicide, with the option to select multiple responses. The findings are presented in the Table 3.

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Table 3. Support wanted after a patient suicide.

https://doi.org/10.1371/journal.pone.0356052.t003

4.1 Experience of psychiatrists following patient suicide

Among psychiatrists who participated in this study, the majority reported having experienced the loss of a patient to suicide. These findings are consistent with studies from the United Kingdom and Thailand [4,22]. Several studies suggest that early-career clinicians are particularly vulnerable to the emotional impact of patient suicide due to clinical inexperience and limited exposure to coping strategies during training [8,23].

Common emotional responses reported in this study included sadness, guilt, and regret, which are consistent with findings from studies conducted in the United Kingdom, Saudi Arabia, and across multiple countries in systematic reviews [3–5,24]. Although these emotional reactions appear relatively consistent across cultural settings, coping strategies, help-seeking behaviours, and perceptions of support may be influenced by local cultural, religious, and healthcare system factors. These reactions align with grief responses observed among other suicide loss survivors, suggesting that psychiatrists experience comparable bereavement reactions despite their professional role [12]. This study reported a detrimental effect in clinical confidence following the loss. The duration of this effect varied among psychiatrists from weeks to years with some psychiatrists reporting ongoing distress at the time of the study. This variability in impact is consistent with the framework proposed by Cerel et al., which categorises individuals exposed to suicide into four groups: suicide-exposed, suicide-affected, and suicide-bereaved (short-term and long-term), depending on the level of attachment and the personal impact of the loss [13]. Psychiatrists in this study appeared across all categories, reflecting the varied ways in which clinicians process and are affected by patient suicide. This study also found that emotional distress was associated with perceived responsibility for the patient’s death indicating that self-blame may be a mechanism intensifying and prolonging distress following patient suicide [25]. As psychiatrists in Malaysia often assume both clinical and therapist roles, the degree of emotional impact may be influenced by the depth of the therapeutic relationship and perceived responsibility toward the patient.

Female psychiatrists in this study reported greater impact and higher perceived responsibility following patient suicide than male psychiatrists which is consistent with previous findings [4]. This suggested gendered patterns in self-blame and emotional processing among clinicians and may warrant targeted support considerations.

In terms of clinical practice, most psychiatrists in this study reported heightened vigilance in suicide risk assessment following a patient’s suicide. Similar findings have been reported internationally. Studies from the United Kingdom, Switzerland, and Saudi Arabia found that clinicians often become more attentive to suicide risk factors, engage in more detailed risk assessments and documentation, adopt more cautious clinical decision-making, and in some cases demonstrate a greater tendency towards defensive practice or hospitalisation of high-risk patients [3,17,24,26]. The consistency of these observations across diverse healthcare systems suggests that increased vigilance may represent a common professional response to patient suicide.

From one perspective, increased vigilance may reflect post-traumatic growth, whereby clinicians adapt following a traumatic professional event through reflective learning and enhanced professional insight [16]. Other themes identified in this study, particularly reflective learning and increased understanding of suicide risk, align with this growth-oriented interpretation. This suggested that clinicians may integrate the experience into their professional identity in ways that strengthen future clinical judgment.

An alternative interpretation is that increased vigilance may reflect hypervigilance, a phenomenon commonly described in post-traumatic stress reactions following highly distressing events. In the context of patient suicide, clinicians may become more alert to suicide risk, engage in repeated checking behaviours, or experience heightened concern about overlooking warning signs. However, as post-traumatic stress symptoms were not directly assessed in this study, it is not possible to determine whether the reported vigilance represents a trauma-related response. Future studies incorporating validated measures of post-traumatic stress may help clarify this relationship.

However, the same behavioural shift may also be interpreted through the perspective of defensive medicine. Defensive clinical practices are typically characterised by increased caution, heightened risk aversion, and extensive documentation, driven primarily by fear of blame, litigation, or professional scrutiny rather than by evidence-based improvements in patient care [20]. In such contexts, increased vigilance may function more as a protective strategy for the clinician than as a mechanism for improving therapeutic outcomes.

Importantly, this study found that increased vigilance often co-occurred with loss of confidence. This pattern mirrors findings from the “second victim” literature, which describes how healthcare professionals involved in adverse events may experience shame, self-doubt, hypervigilance, and emotional distress that influence subsequent clinical decision-making [14,15]. Without adequate postvention support, these reactions may push clinicians toward overly conservative or fear-driven practices that risk undermining therapeutic alliance and clinician wellbeing.

Career-related consequences following a patient’s suicide were relatively uncommon in this study, with only a small minority of psychiatrists who participated in this study considering a change in career or relocation of their practice. Similar consequences have been reported internationally, although at substantially higher rates. In the United Kingdom, 27% of psychiatrists reported considering a change in career following a patient suicide [4], while 35.5% of psychiatrists and psychiatrists in training in Ireland reported similar thoughts [9]. In contrast, only 8.4% of respondents in this study considered changing their career. The low proportion of respondents contemplating career change may also reflect a sense of professional resilience or strong vocational identity within psychiatry. However, it is important to recognise that the absence of career exit does not equate to the absence of harm, as ongoing distress or defensive practice may persist even when clinicians remain in their roles.

The impact of losing a patient to suicide on psychiatrists may be shaped by a combination of personal, professional, and organisational factors. Nearly half of respondents reported moderate to high levels of perceived responsibility immediately following the suicide, although these feelings diminished over time. This pattern could be described as acute self-blame and guilt as early reactions that may gradually lessen as clinicians engage in reflection and cognitive reappraisal. The strong positive association between emotional distress and perceived responsibility further indicates that heightened self-blame may function as a marker of psychological vulnerability rather than objective culpability. This interpretation is consistent with findings from a national survey of French psychiatrists, in which the feeling of responsibility for the death was strongly associated with negative emotional impacts [11], and with qualitative evidence showing that self-blame and self-depreciation in trainees following patient suicide reflect maladaptive psychological responses rather than accurate assessments of fault [27]. This aligns with the broader bereavement literature, in which self-blame has been identified as a powerful determinant of grief-related difficulties [28], and with psychodynamic frameworks describing how guilt and internal persecution in clinicians following patient suicide are driven by psychological defence mechanisms rather than objective culpability [25].

Professional beliefs and systemic pressures also appear to shape the impact of patient suicide. Most psychiatrists viewed suicide prevention as a core professional responsibility and reported substantial external pressure to prevent suicide, alongside beliefs that suicide is at least somewhat predictable. These findings reflect a broader pattern described in the literature, wherein psychiatrists are commonly expected to assess and manage suicide risk as a primary professional duty. It is a role so deeply embedded in professional identity that when a patient dies by suicide, clinicians’ core assumptions about their competence and capacity to heal are often profoundly challenged [29,30]. Indeed, unreasonable systemic expectations of suicide predictability have been shown to directly amplify clinicians’ sense of responsibility following a patient’s death, reinforcing an unrealistic perception of control that is unsupported by evidence on the inherent limitations of suicide risk prediction [31]. These perceptions may amplify distress when a suicide occurs, contributing to moral distress. Moral distress is defined as the psychological unease experienced when a professional perceives themselves as unable to fulfil what they regard as an ethical obligation, despite having acted appropriately [32] or driving defensive clinical practice. The latter has been empirically demonstrated in surveys of psychiatrists, where perceived professional liability for suicide outcomes was directly associated with higher rates of defensive medicine, particularly among younger and less experienced clinicians [33]. Additionally, more than half of psychiatrists were unfamiliar with formal procedures following a patient’s suicide, highlighting organisational gaps that may exacerbate uncertainty and emotional burden.“

4.2 Support following patient suicide

Findings from this study highlight substantial gaps between psychiatrists’ support needs following a patient suicide and the support that is actually accessed or available within the Malaysian healthcare system. Currently, the treating psychiatrist will be responsible for conducting postvention support for the family following a suicide. This includes administrative tasks such as mortality review, for which no adequate formal support is provided.

Despite high levels of emotional impact, only a small proportion of psychiatrists sought external support, and the vast majority did not take time off work. This pattern may reflect a culture of professional stoicism, stigma and shame, or fear of being perceived as clinically incompetent, rather than an absence of distress [25].

Workplace-based support emerged as the most salient protective factor. Collegial support and peer discussions were frequently described as helpful, particularly when colleagues had lived experience of patient suicide. Such peer validation may reduce isolation and normalise emotional reactions. The importance of collegial support and supportive leadership identified in this study is consistent with findings from international research. A systematic review by Sandford et al. reported that peer support, opportunities for reflective discussion, and supportive organisational responses were among the most frequently cited protective factors following patient suicide [17]. Similarly, studies from the United Kingdom, Belgium, and Saudi Arabia have found that clinicians value support from colleagues who have experienced similar events, compassionate leadership, and non-blaming workplace cultures [3,24,26,34]. These findings may be understood through the lens of the second victim phenomenon, whereby the psychological impact of an adverse event is influenced not only by the event itself but also by the organisational response that follows.

Supportive leadership and supervision were also critical. Respondents valued senior clinicians and heads of department who adopted non-blaming, transparent, and compassionate approaches. In contrast, blaming attitudes, minimisation of the event, and lack of senior representation during formal reviews were experienced as particularly harmful, intensifying guilt and distress.

Clear organisational procedures following patient suicide were identified as another important form of support. Over half of the psychiatrists reported being unfamiliar with formal processes after a suicide, suggesting systemic inadequacies. Uncertainty around medico-legal procedures, investigations, and communication with families may compound distress and contribute to defensive clinical practices. Access to clear guidelines, defined roles, and structured debriefing processes may therefore serve both emotional and professional protective functions.

Beyond organisational factors, personal coping strategies played a meaningful role. Support from family and friends, personal reflection, and spirituality were commonly cited as helpful. The prominence of spiritual and faith-based coping is particularly relevant in the Malaysian context and mirrors findings from other Asian settings [22]. Similar findings have been reported in other Muslim-majority settings. In Saudi Arabia, nearly 24% of psychiatrists and psychiatry trainees reported using religion or spirituality as a coping strategy following patient suicide or serious suicidal attempts [24], while another study found religion to be among the most commonly utilised coping strategies among psychiatrists [26]. These findings suggest that spiritual and religious beliefs may serve as important sources of meaning-making, acceptance, and resilience following emotionally challenging clinical events. Postvention frameworks developed for Muslim-majority settings may therefore benefit from recognising and incorporating faith-based coping alongside professional and organisational support mechanisms.

Importantly, when asked about desired support, psychiatrists expressed a clear preference for structured, proactive interventions rather than ad hoc or self-initiated help-seeking. Personal debriefing, senior clinician mentorship, organised peer support, confidential reflective spaces, and guidance on communicating with bereaved families were among the most frequently endorsed needs. These preferences suggest psychiatrists are not opposed to support but are limited by a lack of accessible, confidential, and institutionally endorsed postvention services.

Malaysia has an existing national Guideline on Suicide Risk Management in Hospitals, which outlines procedures for suicide prevention, incident reporting, mortality review, and post-incident management following inpatient suicide. The guideline includes recommendations for staff debriefing and counselling after such incidents. However, its primary focus is on patient safety, organisational response, and service improvement within hospital settings rather than on the longer-term emotional impact of patient suicide on psychiatrists or structured clinician-focused postvention support. The findings of the present study highlight the need to strengthen this aspect of postvention care for mental health professionals.

This study has several limitations. First, the cross-sectional design restricts the ability to determine temporal relationships or draw causal inferences. The sample may not be fully representative of the wider psychiatrist population, as recruitment was dependent on approval and access from participating centres, which may have introduced selection bias and limited generalisability. The psychiatrists with particularly strong experiences or views regarding patient suicide may have been more likely to participate. Conversely, those who found the experience highly distressing may have chosen not to participate, potentially influencing the findings. The snowballing method may also lead to a lack of representativeness, as some psychiatrists may not be aware of the survey. Third, the qualitative component was based on free-text responses within the survey rather than in-depth interviews or focus group discussions. As a result, the qualitative data may lack depth and richness, limiting a more nuanced exploration of participants’ experiences and perspectives.