When it's really dark

Content note: this section talks about suicide and thoughts of suicide. It does not describe any method.

If you are not safe right now, stop reading and call:

• Tele-MANAS: 14416 or 1-800-891-4416 (free, 24x7)
• Vandrevala Foundation: +91 9999 666 555 (call or WhatsApp, 24x7)
• Emergency: 112

You do not have to explain everything on the call. You can say, "I am not safe right now."

The person who built Resident MindMate wanted you to read this line first: "Sometimes staying alive is more important than living. Things can obviously be sorted."

Exams, ranks, the thesis, the HOD, the posting, the family conversation: all of that can be dealt with later, one piece at a time. Tonight the only job is to stay alive.

Resident MindMate is for everyday coping. It is not a replacement for professional help. See When it's time to talk to someone.

Tele-MANAS: 14416 or 1-800-891-4416 (free, 24x7). Vandrevala: +91 9999 666 555 (call or WhatsApp, 24x7). Emergency: 112.

If one line does not connect, try the other. Keep Tele-MANAS as your backup. iCall (9152987821) is open Monday to Saturday, 8 am to 9 pm only, so it is not a night-time line.

Some small steps. Pick any one.

1. Make your goal the next hour, not the next year.
2. Do not stay alone. Go to where people are: the duty room, the nursing station, a friend's room. Or call a friend and ask them to come over and stay. You can tell them, "I'm not OK and I don't want to be alone."
3. Put distance between yourself and anything you could use to hurt yourself. Ask someone you trust to hold on to things for you for now.
4. Eat something and drink water. Hunger and tiredness make everything feel heavier.
5. Breathe out slowly a few times. Then name five things you see, four you can touch, three you hear, two you smell and one you taste.
6. Leave big decisions for the morning.

Getting to morning is enough for tonight.

A safety plan is a short written list you make on a better day, so that on a bad day you do not have to think. It is a list of what to do and who to contact, in order.

The best-known version is the Stanley-Brown Safety Planning Intervention. It was designed to be made with a clinician, and it includes more than the form: an assessment and follow-up as well. In a US study of emergency departments, people who got it had 45% fewer suicidal behaviours afterwards. That study compared groups; it was not a randomised trial.

So you can use the next card to write a rough draft on your own. Then review it with your counsellor, your psychiatrist or Tele-MANAS (14416). A plan made with someone who knows how to do this works better than one made alone.

Keep your plan where you will find it: in your phone notes, in your wallet, or taped inside your locker.

These six headings follow the steps of the Stanley-Brown plan. The wording here is ours. Write a few lines under each.

1. My early signs. What thoughts, moods or situations tell me a bad phase is starting? For example: not sleeping after nights, skipping meals, avoiding the phone.
2. Things I can do by myself. What calms me or distracts me for ten minutes? A walk, a song, a shower, a video, a cup of tea.
3. People and places that take my mind off it. Who can I sit with, or where can I go, without needing to explain anything?
4. People I can ask for help. Who can I tell, "I'm not doing well"? Write their names and numbers.
5. Professional help. Tele-MANAS 14416 or 1-800-891-4416 (free, 24x7). Vandrevala +91 9999 666 555 (24x7). My college counsellor or psychiatrist, if I have one. Emergency: 112.
6. Making my space safer. Talk to your counsellor or psychiatrist about how to keep things you could use to hurt yourself away from you, and who can help with that. You do not need to write those things down here.

Review this draft with a professional when you can.

Doctors are often the last to notice it in themselves. Dr Jake Goodman, a psychiatrist, said of his own depression in residency: "I diagnose people with this every day, and I didn't even recognize it in myself." (See the "They came through" section.)

Signs that you may be heading somewhere dangerous include:

• feeling you are a burden to others
• pulling away from people, or feeling cut off even when people are around
• sleeping far too little or far too much
• losing all joy in things you used to care about, or feeling angry most of the time. Dr Scott Pasichow noticed these burnout signs during his emergency medicine residency, before suicidal thoughts followed.
• using alcohol, tobacco, cannabis or other drugs to cope. In the NMC survey, 19% of PG residents said they felt the need to do this.
• any thought of suicide, even one that feels like a passing joke.

If you see these in yourself, tell one person today. Use your safety plan, or call Tele-MANAS at 14416.

You may notice things about a co-PG before they notice them themselves. In several of the stories in Resident MindMate, a fellow resident or a faculty member noticed first.

Things to watch for:

• They talk about being a burden, or about everyone being better off without them.
• They withdraw: they skip meals with the batch, stop replying, or keep to their room.
• Their sleep changes a lot, much more or much less than their duties explain.
• They stop enjoying things they used to like, or seem flat or unusually angry.
• They make comments about dying or suicide, including ones framed as jokes. Take those seriously. Guidance for young people online says to take it seriously "even if it's said as a joke" (#chatsafe).

You do not have to be sure before you check in. The next card covers how to ask.

If you are worried about someone, ask them in private, one to one, not in a group chat.

Use plain words. For example: "You've seemed really low lately. Are you thinking about suicide?" or "Are you thinking about ending your life?"

Asking directly does not put the idea in their head. A review of the studies on this found no increase in suicidal thoughts when people were asked, and suggests that talking about it may reduce them.

Then listen. You do not need to fix anything. Let them talk, and let silences happen.

If they say yes:

1. Thank them for telling you. Stay calm and stay with them.
2. Help them call Tele-MANAS (14416 or 1-800-891-4416) or Vandrevala (+91 9999 666 555) now. You can sit with them while they call.
3. If they are in danger right now, call emergency: 112, and do not leave them alone. #chatsafe guidance says that getting someone life-saving help is more important than keeping their secret.
4. Help them tell one more person: a senior they trust, a faculty member, or a family member.

After it is over, talk to someone yourself. Helping a friend through this is heavy.

Things that help:

• "I'm glad you told me."
• "I'm not going anywhere."
• "You don't have to have the words ready."
• "Can we call someone together?"
• Asking about the practical things: "Have you eaten? When did you last sleep?"

Things to avoid:

• Arguing about whether their feelings make sense.
• Brushing it off, even if they framed it as a joke (#chatsafe).
• "Others have it worse" or "think of your parents". These add guilt and close the conversation.
• "Everything will be fine." You do not know that, and they know you do not know it. "People do get through this, and help works for a lot of people" is honest.
• Promising to keep it secret. If they are in danger, you will need to tell someone.
• Leaving them alone if you think they are in danger right now.

Use words like "thoughts of suicide", "attempt" and "died by suicide". Avoid "committed suicide".

Content note: this card is about losing a colleague to suicide.

If someone in your batch or hospital has died by suicide, what you feel may include grief, shock, anger, guilt or numbness. All of these are normal reactions to a loss.

• Grieve the person. Remember who they were, not how they died.
• Do not look for one cause. Suicide is complex, and pinning it on one reason oversimplifies it. Avoid saying it was because of the HOD, the exam or the family. That kind of story hurts people who are already grieving and does not explain what happened.
• Do not share details. Do not pass on how or where it happened, any notes, photos or videos, in person or in group chats. If someone shares these, you can ask them to stop.
• Protect their privacy and their family's.
• Check on the people closest to it. Their unit, their roommates and the people who were on duty.
• Check on yourself. A death like this can bring up your own dark thoughts, or make old ones louder. If that happens, call Tele-MANAS at 14416 or Vandrevala at +91 9999 666 555. That is a normal and sensible thing to do.

It is fine to take time before you talk about it at all.

The owner's words again: "Sometimes staying alive is more important than living. Things can obviously be sorted."

This is not a promise that everything will be fine. It is something that the evidence and people's own accounts both show.

• Guidance used by the WHO and by suicide-prevention groups notes that stories of people who came through a suicidal crisis can lead to fewer suicides. That is why Resident MindMate has a section of those stories.
• Coping skills, support and treatment work for most people who have thoughts of suicide.
• Doctors in the stories here who had depression, burnout and suicidal thoughts during training finished, went back to work, or chose a different path that suited them. Dr Jake Goodman described getting better as putting on glasses and seeing "in color again".

A phase can feel permanent while you are in it. That feeling is part of the phase, not a fact about your future.

If you are in a dark phase now, the next step is small. Tell one person, or call Tele-MANAS at 14416.

Resident MindMate is for everyday coping, and it has limits. It is time to talk to a professional if:

• you have any thoughts of suicide or of hurting yourself. Do this today, not after exams.
• low mood, emptiness or anxiety has stayed for a couple of weeks and is not lifting on your off days.
• you cannot sleep even when you get the chance, or you sleep and never feel rested.
• you are making mistakes at work that worry you, or you feel you cannot think clearly.
• you are relying on alcohol or other substances to get through.
• people close to you have said they are worried about you.

You do not need to be at your worst to get help. Earlier is easier.

Where to start:

• Tele-MANAS: 14416 or 1-800-891-4416. Free, 24x7, run by the Ministry of Health. You reach a counsellor.
• iCall (TISS): 9152987821. Monday to Saturday, 8 am to 9 pm.
• Vandrevala Foundation: +91 9999 666 555. Call or WhatsApp, 24x7.
• Your college psychiatry department or counselling cell, or a psychiatrist outside your hospital.
• Emergency: 112.

The first call. When you dial 14416, a counsellor answers. You do not need a script. "I'm a resident, and I haven't been OK for a while" is enough to start. You can say as much or as little as you want.

The worry about confidentiality. Many residents worry that the department, the HOD or the college will find out. That worry is real. At least one DNB resident has described being accused of faking mental-health leave.

What the law and Tele-MANAS say:

• The Mental Healthcare Act 2017, section 23, gives a person with mental illness a right to confidentiality, and health professionals treating them have a duty to keep that information confidential. There are listed exceptions, such as protecting someone from harm or a court order.
• Tele-MANAS says what you tell a counsellor is confidential, and calls are not audio-recorded. It is not anonymous: your number is stored in masked form and kept for 3 years. It can be shared if there is an immediate risk to your life or to someone else.

What the NMC has said: its 2024 Task Force recommends confidential counselling with "a firewall (confidentiality) between counselling service providers and the medical college faculty". This is a recommendation. Your college may or may not have set it up.

Some practical choices:

• Tele-MANAS is a national government line, outside your college.
• You can see a psychiatrist who is not in your own hospital.
• Before you share anything with a college service, you can ask, "Who will see my notes, and does anything go to my department?"

Getting help is the right call even when the system around you is not perfect.