Psychiatry Grand Rounds: November 13, 2020

November 13, 2020

Information

"The Ebb and Flow of Suicide Risk: Implications for Treatment"

Stress, Trauma and Resilience (STAR) Professor of Psychiatry and Behavioral Health; Director, Division of Recovery and Resilience; Director, Suicide Prevention Program and Trauma Program, The Ohio State University College of Medicine.

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00:00Good morning everyone.
00:01It's great to see so many friendly faces
00:05in that bar on the right of my screen.
00:08I have the pleasure and honor of
00:11introducing Craig Brian this morning.
00:13I first actually got to know Craig
00:15in 2015 after reading a paper in
00:18the American Journal of Psychiatry,
00:20randomized controlled trial that
00:22he had done with David Rudd.
00:25That actually showed a 60%
00:27reduction in suicide attempts among
00:28active duty military personnel,
00:30which really caught my interest.
00:32So I reached out to Craig and David
00:35and started talking with them,
00:37learning more about their work
00:39and ultimately became a friend
00:42and admirer of his work.
00:43I looking very much looking forward
00:45to his talk today because I think
00:47there's data in it I'm not aware of.
00:50Craig is a clinical psychologist.
00:52He's the star professor of Psychiatry
00:54and Behavioral Health at the Ohio
00:57State University Wexner Medical Center.
00:59And is the division director for
01:02Recovery and resilience there.
01:03He did his doctorate in Clinical
01:05Psychiatry at Baylor University,
01:07completed clinical residency at
01:08the Wilford Hall Medical Center,
01:10Lackland Air Force Base,
01:11and was deployed in Iraq in 2009 and
01:14was the director of the traumatic
01:17Brain Injuries Clinic at the Air
01:19Force Theater Hospital there.
01:21He left active duty service and started
01:23researching post traumatic stress disorder,
01:25suicidal behaviors and
01:26suicide prevention strategies,
01:27as well as psychological health
01:29and resiliency.
01:30He's had faculty appointments at
01:31the University of Texas Health,
01:33same health system in San Antonio,
01:35the University of Utah,
01:37and now at the Ohio State University.
01:39He's had 10s of millions of dollars
01:42in grants focused on these topics.
01:44Suicide prevention,
01:45PTS di trauma and resilience.
01:47One has won many awards.
01:48I won't go into all of them.
01:51And I'll just let him dive in and
01:54get right to it.
01:55So Craig, thanks so much for coming.
01:57Thanks for everyone for attending.
01:58If you have questions,
02:00please enter them into the chat and
02:02when Craig is done we can go through
02:04them and try to get to them all.
02:06So thanks.
02:09Alright well thanks for the introduction.
02:11It's really great to be able to join all
02:14of you this morning and seeing a little
02:16bit of windows and in my boxes here,
02:19it looks like you guys are having a nice day.
02:23Up there in the Connecticut area and a
02:26beautiful day here in central Ohio as well.
02:28So today what I thought
02:30I would talk about is.
02:32More of some conceptual work around
02:35suicide that we've really been focusing
02:37on over the past several years now.
02:40Certainly present some of the
02:42empirical findings at our lab and
02:45other labs have published in recent
02:47years that really kind of backup.
02:50This sort of approach to understanding
02:52suicide and suicidal behavior.
02:54And then, after we kind of start with
02:57more kind of conceptual ideas about
03:00thinking of suicide in new ways.
03:03You know,
03:04I'll conclude with some of the work
03:06that we've done from an intervention
03:08and prevention standpoint,
03:10and how I think this alternative approach
03:12to understanding the emergence of
03:14suicidal behavior and might lead us to
03:17think about a range of interventions
03:19in a number of strategic ways.
03:22So the you know the basis for
03:24this line of research really was,
03:27you know, founded in.
03:28I think some traditional ideas
03:30about suicide prevention.
03:31I think some of the traditional
03:33ways that we have approached
03:35our understanding of suicide and
03:37approached prevention efforts are
03:39encapsulated in many ways by a lot
03:41of the catch phrases and sayings
03:43that I have on the screen right now,
03:46that I'm sure many of you are familiar with.
03:49You probably heard this plenty often.
03:52I'm going to maybe you as well as
03:54mental health professionals and
03:56researchers have said one or more of
03:58these things as well when talking
04:01about suicide and I start here because
04:03I kind of think that where we're
04:06heading now in in our research on
04:08suicide prevention is really a mini
04:10wasted on the cusp of a paradigm shift.
04:13And I think it's critical for us
04:16to understand where we come from
04:18as we talk about and think about
04:21where we're heading.
04:22So one of the challenges, of course,
04:25when it comes to suicide,
04:27is that despite decades of fairly consistent,
04:30I would argue fairly uniform thinking
04:32about suicide over the past two
04:35decades since the turn of the century,
04:37we've seen a steady rise in
04:40suicides in the US,
04:41and which is not really mirrored
04:43anywhere else in the world.
04:46About 3/4 of nations around the
04:48world during the same time frame.
04:50If you look at statistics reported too.
04:53Mental Health Organization.
04:55See that most nations are actually
04:58experiencing a decline in suicide
04:59rates in the United States is one of
05:02the minority that is actually seeing
05:04the reverse pattern occur ING in.
05:07On top of that, if we were to rank order.
05:11You know all the world's nations in
05:14terms of change in suicide rates since 2000,
05:17we see that the United States is
05:19actually #3 in terms of the fastest
05:21and the largest increase in suicides.
05:24And so there's something very unique I think
05:26about the United States that's different
05:29that Bing's very clearly are not working,
05:31at least not in the way that we would like,
05:35which has really stimulated
05:36me and others to second guess.
05:38A lot of those initial assumptions
05:41that I shared with you.
05:42Maybe there's something about the way
05:45that we've approached suicide and.
05:46Thought about it.
05:48That isn't really accurate.
05:49Or maybe we're missing the mark in some way.
05:52'cause if we were if we were correct
05:55about how we understand suicide in
05:58our interventions were as effective
06:00as we think they should be,
06:02then probably we would not be seeing
06:05this upward steady rise in suicide.
06:07We should be seeing either things
06:10holding steady or even a decrease.
06:13So as I think about what are some of those
06:16classic ways that we conceptualize suicide,
06:19I really think that many of the theories
06:21that have been proposed and there are
06:24a multitude of theories about suicide.
06:27In many ways,
06:28conform to this general framework.
06:30We could certainly probably quibble
06:32and argue about differences and
06:34the different theoretical models,
06:36but I think that this this sort of
06:40sequence of events, so to speak,
06:42kind of serves as a sort of a
06:45foundational way of capturing how
06:48we have thought about suicide.
06:50Where you know someone experiences
06:52an intensification or elevation of
06:55emotional distress and then some things
06:57happen, certain mechanisms occur.
06:59Different theories would posit
07:01different mechanisms,
07:02but something is happening whereby
07:04emotional distress evolves into
07:06suicidal ideations and then at that
07:09point individuals were thinking
07:11about suicide again.
07:12Some kind of mechanisms or processes occur.
07:16Different theories, again,
07:17are proposing different mechanisms,
07:19and then individuals transition
07:21to suicidal behaviors.
07:22So in essence,
07:24they act upon the suicidal thoughts
07:26and then another sort of typical
07:30assumption about.
07:31The sort of progression from ideations
07:34to action is that relatively soon
07:37before a suicide attempt occurs,
07:39there are theoretically some observable
07:42changes are observable variables that
07:45we refer to as warning signs that should,
07:48in theory signal that a suicide
07:51attempt is about to occur.
07:54So I would say despite in many ways
07:58this serving is kind of a foundational.
08:02Assumption about how we think about suicide.
08:05As I noted on the previous slide,
08:08we're not really good at preventing suicide,
08:10at least not in the United States,
08:13and so it's really prompted myself
08:15and a number of other researchers
08:18to question a lot of our long held
08:21assumptions about suicide and to start
08:24thinking about this in different ways.
08:26And so I just want to kind of
08:30talk today about some of my own.
08:32Halfway my own thinking over the
08:35past several years and kind of talk
08:38about how different experiences
08:40different studies have led us to to
08:43really approach our understanding
08:44of this emergent process of moving
08:46twords suicidal behavior that we
08:48think can potentially advance our
08:51ability to prevent suicide.
08:52And in many ways,
08:54sort of.
08:55I would kind of tie the
08:57origins of my thinking
08:59about this to some conversations
09:01that I had with a colleague of mine.
09:04In Utah. You know the first arrived.
09:08There's faculty, especially the
09:10conversations I had with John Buckner,
09:13whose social quantitative psychologist his
09:15expertise in complex dynamical systems.
09:17And we were having coffee one day on campus,
09:21just kind of chatting about our respective
09:24programs, getting to know each other,
09:27and it so happened that each of us had
09:30been funded by NASA to do some work,
09:34and in his project in his NASA.
09:37On the project is kind of interesting.
09:40He was being asked to model budget
09:42overages and what NASA's concern was,
09:45hey, you know we have all these grants.
09:48We've all these contracts and
09:50projects that we're funding.
09:51You know, the vast majority of them.
09:54They spend money as expected.
09:56They perform on track,
09:57so they're not really issues for us.
10:00We obviously don't worry about
10:02projects that achieve their
10:04objectives on time and on budget.
10:06And then there's another pool of
10:08projects where the projects are
10:10fairly consistently over budget.
10:12They're not dramatically over budget,
10:14but they are always spending more
10:16than what was initially projected,
10:19but there still achieving their
10:21milestones and an absolute told him,
10:23you know,
10:24we're not really worried
10:25about those projects either,
10:27because they're predictably over budget.
10:29We know exactly how much
10:31they're going to spend.
10:33And probably it's just we we
10:35probably just under estimated the
10:37resources needed for those projects,
10:39but they're doing OK,
10:40But there's this third group of projects.
10:43That are really, really problematic for NASA,
10:47and it's because.
10:48They initially start on track there,
10:51performing well they're spending as expected,
10:54and then all of a sudden
10:56they're massively over budget,
10:58and then once they seem to
11:00depart from being on track,
11:02they have one period where their massively
11:05over budget things just get worse and worse.
11:08They keep coming up over budget,
11:11over budget over budget dramatically,
11:13and so this creates this massive
11:15problem for the organization because it
11:18shuts down other projects it creates.
11:20Budget strain for everybody else.
11:22All of the projects depending
11:24on that one particular project,
11:25it slowed down and so NASA
11:28had actually a term for it.
11:30They called it,
11:31performance escapes,
11:31and so they wanted John to help
11:34figure out how do we know which of
11:37our seemingly on track OK projects
11:39are going to suddenly out of the blue
11:42turn into project escapes and and so
11:44John was modeling this mathematically.
11:46This is one of the simulations
11:48that he ran using their data and
11:51you see here there's just like 1
11:53project that sort of taking off.
11:56This is a performance escape as compared
11:58to all the other projects that are sort
12:00of clustered on their spending there.
12:02They're kind of on track,
12:03and as we're talking about
12:05these performance escapes.
12:07He said,
12:07you know,
12:08that's interesting that what you're
12:10doing there because you know I'm a
12:13suicide researcher and one of our
12:15big problems that we run into him.
12:17Clinicians. We have some family members,
12:19lots of people is that
12:21suicide seems unpredictable.
12:22Patients will seem to be doing OK in
12:24treatment and then suddenly they're dead.
12:27Family members say everything
12:28seemed to be OK.
12:30They seem to be fine.
12:31And then all of a sudden
12:33they had attempted suicide,
12:35and so there is this sort of subgroup.
12:38Of suicide cases that seem to align with
12:41this notion of a performance escape,
12:44and we also have known for
12:46several decades if there's a,
12:48there's a significant percentage in some
12:50studies up to half of those who attempt
12:53suicide who deny suicidal planning.
12:56Severe suicidal ideations,
12:57where they seem to like skip these
13:00intermediate steps that we have long held
13:02to be a necessary precondition for suicide.
13:05The assumption that many of us have.
13:08Worked on for many years is that
13:10will you have to think about
13:12suicide in order to attempt suicide.
13:14But for whatever reason,
13:16there's a significant percentage of suicide
13:18attempt survivors who are saying no.
13:20Actually,
13:20I didn't do that.
13:21I skipped that step and
13:23so we were really there.
13:25Seems to be a lot of parallels
13:27between these sort of budget overages.
13:30And suicide.
13:30And so this is in many ways that
13:33sort of the pre genitor of a lot of
13:36our collaboration together to start
13:38thinking about suicide in unique ways.
13:42And this is where I started to become
13:45familiar with dynamical systems theory
13:47and one of the key concepts within
13:50that mathematical sort of branches.
13:52This notion of emergence and emergence
13:55just in general kind of refers to the
13:58process of coming to be how something.
14:01That was not there before
14:03eventually comes into being,
14:04and this sort of mathematical
14:06concept of emergence is largely
14:08founded upon four key assumptions,
14:10the first of which is that change
14:13within a system is constant.
14:15The second is that the whole is
14:17greater than the sum of its parts.
14:20The third is that each component
14:22of a system depends upon the other
14:25components of that system to function,
14:27and then 4th that complex systems
14:30behave in non proportional ways.
14:32And as John and I started
14:34working together over the years,
14:36we started to apply these principles
14:38of emergence to our study of
14:40suicide and what we're finding
14:42is that it seems to be a very,
14:44very useful way to conceptualize and
14:46think about suicide risk in general.
14:49And as we'll talk about later
14:51on in the presentation,
14:52and I think it is a lot of patients for
14:55clinical practice as well as suicide
14:57prevention strategies in general.
14:59And so I'd like to do is just.
15:02Spent some time talking about how
15:05these four concepts seem to apply to
15:08suicide and how this might change,
15:10or at least advance or upgrade our
15:13thinking about preventing suicide.
15:15And so first,
15:16let's talk about the first
15:18assumption that change is constant.
15:20So this is this notion that
15:22suicide risk is a dynamic concept
15:25that it's always ever changing
15:28really isn't necessarily
15:29a new idea. I mean this.
15:32This is certainly been written
15:34about for many, many decades.
15:36Anyone who's a clinician knows this to be
15:39true that patients are low risk sometimes,
15:41but then they in turn to a high risk state
15:44and then they return to a little risk stage.
15:48But it's only been within the past
15:50decade or so that I think technological
15:52advances and data analytic methods have
15:55gotten to a point where we're able to
15:57quantify it and describe these change
15:59processes with sufficient detail.
16:01And so, for instance, this is a.
16:03This is some of the results from.
16:06Study that Evan Kleiman at Ruckers did
16:09using ecological momentary assessment or MA
16:11where they were basically assessing suicidal
16:14individuals four to six times per day.
16:16They would assess multiple variables,
16:18but this one on the screen right now.
16:21Ask them about several aspects of suicidal
16:24ideations and so they were able to map
16:27out fluctuations in suicidal ideations
16:29over the course of several weeks,
16:31and what you see here.
16:33This is all of the participants
16:35in that study.
16:37Aggregated together in a few of the
16:39cases are kind of drawn out and put into
16:43color to help demonstrate the concepts.
16:45What you see is that variability.
16:48Is the rule not the exception an one of the
16:52more striking findings from climate studies,
16:55at about 90% of participants who were
16:58suicidal experience to 1 standard deviation
17:00or larger shift in their suicidal thinking
17:03within the span of just a few hours.
17:06And so you can see that here in some
17:09places where there are these sudden
17:11dramatic increases in suicide risk,
17:14and then sometimes it's the reverse.
17:16There's a sudden and dramatic
17:18drop in suicide risk.
17:20And every so often there's even these,
17:22like very brief peaks that seem to
17:25correspond with an acute suicidal crisis.
17:27And so this this we're seeing
17:29this pattern over and over again,
17:32not only with the MA studies with some of
17:35the work that I've done modeling change
17:38in suicidal ideations on a weekly basis.
17:40And now a daily basis.
17:42You know,
17:43an intensive outpatient programs,
17:45inpatient settings,
17:46or even outpatient therapy
17:47settings that these fluctuations
17:49and suicide risk are the rule.
17:51Now why this is sort of important
17:53for us to think about from a clinical
17:56perspective is that it provides an
17:59explanation for why suicide risk screening
18:02and assessment is so notoriously unreliable,
18:04and so here on the screen.
18:07Now I have two hypothetical patients,
18:09one depicted in Black,
18:11one depicted in red.
18:12You see that they are experiencing
18:15fluctuations in suicide risk
18:17that are comparable to what we
18:19saw in the previous screen.
18:21Now, if these two patients were to say,
18:24come into an emergency Department
18:26on the same day,
18:27and that day correspond to the arrow
18:29on the left, and we assess them,
18:32perhaps whatever scale that you use with pH,
18:34D 9, the ask the easy save the Columbia,
18:37whatever it is,
18:38what we would conclude on that day
18:41is that the person in black
18:43is higher risk for suicide.
18:45Been the person in red, and so we might.
18:48Perhaps we would consider
18:49hospitalizing the person in black,
18:51but may be discharged.
18:52Person in red to home.
18:54Now if we slide to the right of
18:56this graph to that second arrow,
18:58if those same two individuals had come
19:00into the emergency Department at a
19:02different point in their time series,
19:04we would conclude the exact reverse
19:06person in red is the higher
19:08risk than the person in black.
19:10And so maybe we would hospital as a
19:12person in red instead of the person in black.
19:15Now if we look at the entire
19:17T of the time series, however,
19:19what you would see is that
19:21they actually do not really.
19:22Differentiate from each other.
19:24There's not a whole way a real
19:26way to kind of say that one person
19:28is higher risk than the other.
19:30They're both experiencing these
19:32Upson Downs and this is,
19:33I think a critical new.
19:35Idea that many of us are starting
19:38to find in our studies over and
19:40over again is that suicide risk,
19:43especially suicidal ideations,
19:44isn't really all that useful for
19:47distinguishing between patients
19:48who are higher and lower risk.
19:50And that's largely because
19:51suicidal ideations suicide risk
19:52is a within person phenomenon.
19:54People have good days and bad days,
19:57and so we perhaps need to start shifting.
20:00I'm thinking away from some of
20:02our research models of clinical
20:04decision rubrics that are trying
20:07to distinguish which patients are
20:09going to attempt suicide in which
20:11are not and move towards a thinking
20:13of when is a given individual
20:16vulnerable or in high probability
20:18state to engage in suicidal behaviors
20:21and so along this line of sort of
20:23within person change processes.
20:25We started to now conduct several
20:28studies to really map out and
20:31mathematically model these
20:32fluctuations in suicide risk overtime,
20:35under the assumption that maybe
20:37there are certain patterns of change
20:40within individuals that might signal
20:42the near term emergence of suicidal
20:45behavior such that the concept
20:47of a warning sign, for instance,
20:50isn't necessarily the occurrence or
20:53the existence of a given variable or a given.
20:57Behavior,
20:57but perhaps the warning sign is a
20:59change process that departs from in
21:02individual standard baseline change process.
21:04So on the screen.
21:06Here I give an example.
21:08This on the left hand side of this time
21:11series we see fluctuations and suicide risk.
21:14Then at about the midpoint
21:16of the time series,
21:18what you see is those fluctuations in
21:21suicide risk become more and more prominent.
21:24The amplitude of the Upson Downs increase.
21:27In magnitude,
21:27this is actually a pattern that
21:30we've seen down to separate
21:32studies that have been published,
21:34that it serves as an indicator that
21:37suicidal behavior is coming where in essence,
21:40from a mathematical perspective.
21:42What this signals is a loss
21:44of self regulation.
21:45The system is breaking down in the
21:48system is no longer able to contain
21:51and preserve its homeostatic balance,
21:53and so it's getting
21:55agitated which signals and.
21:57Upcoming emergent shift in states we've
21:59also found in some of our research
22:02that a different but related pattern
22:04relates to the frequency of fluctuation.
22:07So again, here on the left hand side
22:09of the time series we see these
22:12periodic spikes that occur in suicide
22:15risk and then at the midpoint those
22:18spikes in suicide risk occur much,
22:20much more often.
22:22This is a second dimension of
22:24dysregulation such that perhaps
22:26sometimes we see an increase in.
22:28Amplitude of fluctuations.
22:29Sometimes we'll see an increasing
22:31frequency of amplitudes,
22:33and we might also see a combination
22:36of the two.
22:37So if we were to then apply
22:40this to clinical practice,
22:42what this would indicate is
22:44that repeated assessments of
22:46suicide risk overtime state,
22:48like every single therapy session,
22:50every single Med monitoring
22:52session might be able to detect
22:54within person change processes,
22:56which could then signal hey,
22:59this is a departure from the norm.
23:02This is not a typical change pattern
23:04for this particular individual.
23:06They're becoming more dysregulated and so
23:08perhaps that would prompt an intervention.
23:11We're actually working now.
23:12We have a narrow one.
23:14This is kind of the key idea behind
23:17the work that we're currently
23:19doing on a grant to look at.
23:22Could you potentially develop novel
23:24detection and alert systems that
23:26could be implemented in clinical
23:28practice that now takes into
23:30account multiple time points in
23:32applies new mathematical models?
23:34To look at within person, change to signal.
23:36Hey,
23:36this patient is now at a higher
23:39probability risk state and we
23:41should probably intervene with them.
23:44Now the 2nd two concepts of emergency.
23:46I want to talk about here is the
23:48whole is greater than the sum of its
23:51parts in each component of a system.
23:54Depends on the other components to function,
23:56and so this is.
23:57These are sort of two related ideas
23:59that I think is also highly relevant
24:01to our work and suicide prevention.
24:04And to demonstrate these two concepts,
24:06I'm actually going to share with you
24:08a video that I found very sort of
24:11informative in my own thinking about
24:13systems theory and dynamical systems.
24:15So in this video I want to say maybe
24:18like a minute and a half long.
24:21It's sort of outlines the process
24:23of emergence for hurricane and so
24:25hurricanes go through several.
24:27We've sort of classified different stages,
24:29whether that's tropical depression to
24:30a tropical storm to a full blown hurricane,
24:33and then we have different
24:35categories of hurricanes.
24:36But even though there are these unique
24:39sort of stages that we have just sort
24:42of arbitrarily come up with as humans.
24:45There are these sort of continuous
24:47change processes that lead you know
24:49weather patterns to kind of move through
24:51these different arbitrary stages.
24:53So as we watch this video,
24:55the thing I wanted to just pay attention
24:58to is again this notion of complexity.
25:01How different variables are
25:02interacting with each other and
25:04also pay attention to it will
25:06show different arrows moving in
25:08different directions to to
25:10convey some these concepts.
25:14Depends upon the following conditions
25:17coinciding Alarge still and warm ocean
25:19area with the surface temperature
25:22that exceeds 26.5 degrees
25:23Celsius over an extended period.
25:25This allows a body of warm air to
25:30develop above the ocean surface.
25:33Low altitude winds are also
25:35needed to form a tropical cyclone.
25:38As air warms over the ocean,
25:40it expands, becomes lighter and rises.
25:43Other local winds blow in to
25:45replace the air that has risen.
25:47Then this air is also warmed and rises.
25:52The rising air contains huge amounts of
25:54moisture evaporated from the ocean surface.
25:57As it rises, it cools,
25:59condensing to form huge clouds about
26:0210 kilometers up in the troposphere.
26:05More warm air rushes in and
26:07rises drawn by the draft above.
26:10The amazing drafts are there carrying
26:13moisture high into the atmosphere
26:15so that these clouds eventually
26:17become very thick and heavy.
26:20Condensation then releases the latent
26:22heat energy stored in the water vapor,
26:25providing the cyclone with more power.
26:27This creates a self sustaining heat cycle.
26:31Drawn further upwards by the
26:33new release of Energy,
26:35the clouds can grow to 12
26:38to 15 kilometers high.
26:40The force created by the Earth's
26:42rotation on a tilted axis,
26:44the Coriolis effect,
26:46causes rising currents of air to spiral
26:49around the center of the tropical cyclone.
26:52It is at this stage that the cyclone matures
26:55and the eye of the storm is created.
26:58As the air rises and cools.
27:00Some of this dense air descends
27:02to form the clear.
27:04Still,
27:04I as the cyclone rages around it.
27:10So a couple of key ideas in here is that
27:15as the hurricane is a cyclone emerges.
27:19It's not simply that you have to
27:21have wind speed at a certain level
27:24temperature at a certain level have
27:27to be over a suitable body of water.
27:30There's a lot of conditional
27:31interdependence amongst these variables.
27:33It's the right wind speed at the
27:36right temperature in the right place,
27:38under the right conditions,
27:40and if any of these variables shift
27:43or are they off just a little bit,
27:45it can actually dissolve the
27:47entire system when aspect about.
27:49Hurricane formation that I learned
27:51about in the past few years doing
27:54this work is that wind speeds
27:56Tradewinds at very high altitude.
27:58Have to actually be in this
28:00very narrow band of velocity.
28:02If the trade winds are not fast enough,
28:05it does not provide enough momentum
28:07for the hurricane to actually move in.
28:10Things break apart.
28:11Conversely, if the wind,
28:13the trade wind speeds are too
28:15high of a velocity,
28:17it doesn't allow enough time for all
28:19of these other processes to congeal.
28:22And for man,
28:23it basically breaks up the system
28:25and So what we have here then.
28:28Is a system where lots of variables
28:31are interacting with each other
28:33in those variables are changing in
28:35very key ways that we start to see
28:38feedback loops and if those feedback
28:40loops in those change processes
28:42aren't in the right configuration,
28:44then in essence the hurricane doesn't
28:46emerge and so this seems to be
28:49something comperable to suicide that
28:51the conceptual theoretical model that
28:53we use in a lot of our research is
28:56referred to as the suicidal mode,
28:58and this is a graphic depiction of that.
29:02And so a lot of people have
29:04sometimes commented clinicians like,
29:06well,
29:06they're like all these sort of
29:08arrows pointing to different pieces.
29:10You know,
29:10it's sort of like a complicated
29:12model is compared to some of the more
29:15classic like cognitive models or
29:17the biomedical biobehavioral model,
29:18so I've seen.
29:19But what this really captures in
29:21the suicidal motives,
29:22this notion of a network that
29:24lots of different variables are
29:26influencing each other,
29:27and they have to influence each other
29:30in the right way at the right time.
29:33In order for the conditions to be
29:35right for suicidal crisis to emerge,
29:38and then critically for suicidal
29:40behaviors to emerge,
29:41and some of the newer research
29:43that's being done right now,
29:45particularly IMA researchers that are
29:47using network computational models,
29:49is showing us that there actually
29:51are multiple pathways suicide.
29:53One of the limitations of a lot
29:56of our traditional thinking about
29:58suicide is that we focus on.
30:00One or two risk variables or factors.
30:03Hopelessness, perceived,
30:04burdensomeness thwarted belonging.
30:06This fearlessness about death or
30:08some of the ones that are more
30:11popular that are more well known.
30:13But what we're seeing now using these
30:17more complex dynamic models is that,
30:19you know,
30:20hopeless hopelessness is a primary
30:22factor in firmly some suicidal people.
30:25Perceived Burdensomeness is an
30:27important variable for a different group
30:29of individuals, but in essence.
30:31The reason may be that we haven't
30:33been better at preventing suicide
30:35as we create these monolithic
30:37models that don't have sufficient
30:39complexity and therefore don't allow
30:41us to fully understand the different
30:43processes by which suicide might be
30:45a common endpoint of another way of
30:47saying this is sort of like there.
30:49There might be multiple roads to Rome,
30:52but because we assume there's
30:53only one Rd to Rome,
30:55we're not doing a good job setting
30:57up the barriers on all of the
31:00many different roads to block
31:01their pathway to get to room.
31:06I'll say one other point about
31:08that that I didn't mention is that
31:11this notion of interdependence,
31:13where all of these many different factors
31:15and variables influence each other,
31:17and so you know depression.
31:19Hopelessness, for instance,
31:21if you experience an increase
31:22in your hopelessness,
31:24we might reasonably expect
31:25an increase in depression.
31:27Conversely, an increase in depression
31:29might reasonably be expected
31:30to increase once hopelessness,
31:32and so we really can't sort
31:34of parse out and separate.
31:37The notion of depression and hopelessness
31:39and other risk variables because
31:41they all depend upon each other and
31:43we have a study under review right
31:45now or what we did is we use the
31:47best scale for suicidal ideations.
31:49And instead of modeling the scale for
31:51suicidal ideations as a single total score,
31:53which is how most of us are traditionally
31:56used it in looking at that change process.
31:58Overtime,
31:58what we've done is we actually
32:00took each of the individual items
32:02and we said all of the items.
32:04In a sense they can change
32:06in any way they want.
32:08Independence of each other and let's
32:10see what happens in what we found
32:13was that can sort of consistent with
32:15the notion of emergency complexity
32:18be different asset aspects or facets
32:20of suicidal ideations under some
32:23conditions were tightly correlated
32:25with each other such that an increase
32:27in the wish to die corresponded with
32:29an increase in suicidal intent.
32:31But there are other cases in
32:34other circumstances where there
32:35was no relationship between these
32:37two otherwise supposedly.
32:39Correlated facets of suicidal ideations,
32:41and So what we're starting to see,
32:43then,
32:44is that there might be these sort
32:46of different networks and Inter
32:48related webs of risk variables and
32:51processes that have implications.
32:53For prevention is from a network perspective.
32:56We can identify some of the key
32:58variables that are most tightly
33:00influential and interconnected
33:02with other aspects of the network.
33:05What we could start doing, then is targeting.
33:08This is the one thing that if we
33:11can change this one variable,
33:13it has this downstream effect that
33:16ripples out and starts to impact
33:18other risk factors for suicide,
33:20leading to a more efficient
33:22reduction in suicidal crises.
33:24Conversely,
33:24if we're not targeting the
33:26right piece of the network,
33:28we might have interventions that are really,
33:31really good at changing a
33:33particular risk variable,
33:34but that change isn't sufficiently
33:36connected to other members of the network,
33:39and so we don't see that downstream
33:43effect in reduction in suicide risk.
33:46So the 4th concept that I wanted to
33:49talk about is that complex systems
33:51behave in non proportional ways and
33:53what this refers to is that you can.
33:56You can sometimes put a whole lot
33:58of stuff into a system to change
34:01that system and in the system just
34:04sort of ignores all of the input.
34:06It doesn't really change how it behaves.
34:09Conversely you see the opposite
34:11where we don't really do a whole lot
34:14in terms of input or intervention.
34:16And then the the system will
34:18dramatically change in how
34:20it behaves, and so a little bit
34:23and sometimes paying big dividends.
34:26Is a whole lot of input doesn't
34:28really seem to have any effect.
34:30This is like one of those really
34:32frustrating aspects of clinical practice
34:33where some of our patients that come in.
34:35We just really hit them with a lot of
34:38interventions. We really are group,
34:39you know they do therapy.
34:41They do meds.
34:42Did you all sorts of stuff and
34:43then we don't really see a change,
34:46whereas other patients it
34:47seems like they come in.
34:48We have clinicians or like I didn't
34:50really even do anything and now all of
34:52a sudden there dramatically better and
34:54we really don't understand why there
34:56are these differential response patterns.
34:57In one of the possibilities of that well,
35:00complex systems behave
35:01in non proportional ways.
35:03There isn't any guarantee that what you
35:05put in will have a proportional output,
35:08and so I have another video to kind of
35:11display and highlight some of this.
35:13This is a gymnastics example
35:15before I introduces further.
35:16I'll encourage you might want to adjust
35:18your volume a little bit down on this one.
35:22The volume on this video tends to
35:24be a lot louder than the last one,
35:27and so perhaps we can avert some
35:29panic attacks here if we.
35:31Give you a little bit of warning.
35:33This is a 30 second video.
35:35This is Simone Biles.
35:37I'm sure everybody recognizes her
35:39and she's doing one of her routines
35:41and I found that as I was really
35:43trying to understand the concepts of
35:45non proportionality that gymnastics
35:47was like this.
35:48Really really great way of kind
35:50of capturing it.
35:51Embodying this notion of non proportionality.
35:53So let's let's watch your 32nd routine here.
36:19That's I warned a second Trisha
36:21that usually this video and
36:23practice runs works beautifully.
36:25And then during the live
36:27presentation this happens.
36:28Let me try an alternative approach.
36:30Going to switch to you.
36:33Another video here.
36:35Let's see if this works better.
36:45Share this instead.
36:49The same video I'm just going to use
36:52the raw video and maybe that will.
36:54Correct the problem, right? Let's try now.
37:32Right, so I shared that video because
37:36I think it really helps to capture
37:40that notion of that non proportionality
37:43where here we have this undisputed,
37:47very accomplished.
37:48Athlete who's very good at what she does.
37:52Ann is 1 lots of medals and is very very
37:56accomplished and is doing quite well on her.
38:00Routine for the first 29 1/2 seconds
38:02and then she does a split an she lands
38:05on the beam and up until that moment is
38:08sort of like we had absolutely no way of
38:11knowing that she was actually going to fall.
38:14And from the time that we see her
38:17legs shooting up for her trying to
38:19touch her balance to her feet being
38:21on the ground with the fall,
38:23it's about half of a second
38:25so it's very dramatic.
38:27Very rapid,
38:27seemed to come out of the blue despite.
38:30All of this good performance
38:32up until that point.
38:34And so this really sort of aligns
38:36with that notion of the projects
38:39that John was working on with NASA,
38:41as well as some of what we
38:44know to be true with suicide.
38:46That it seems to sometimes come out of
38:49the blue without much advanced notice.
38:52Well that in essence this fall
38:54here that we saw in gymnastics.
38:57It's sort of like we don't really
39:00know what contributed to it.
39:01We can probably infer that maybe she
39:04just landed in a way where her center
39:07of gravity was perhaps just a little
39:09bit off from where she wanted it to be.
39:12Maybe her,
39:13maybe her foot was just twisted in a slightly
39:16different way than what she was expecting.
39:18We really don't know, but a very,
39:21very slight shift in the mechanics of
39:23the move led to this dramatic outcome,
39:25and suicide seems to function
39:27in the same way.
39:29So mathematically,
39:29this is referred to as a catastrophic
39:33change where the system suddenly
39:35shifts from its prior behavior to a
39:38completely different behavioral pattern,
39:40and we've started to think about
39:43catastrophic change processes and apply
39:46it to our work with suicidal individuals.
39:49And we're actually finding it.
39:51It's a very useful model,
39:53and the reason we think this is
39:57the case is that.
39:59Again, from assistance.
40:00Perspective to have these sort of
40:02sudden catastrophic changes,
40:04there's another inherent assumption
40:06embedded within non proportionality,
40:07which is the notion of a tipping
40:10point where there exists two distinct
40:12distinct and discrete States and in
40:15between these two separate states of
40:18being is this tipping point such that
40:20if you fall just shy of the tipping point,
40:24you stay in one particular state.
40:27If however you just barely move
40:29over the cusp of that tipping point.
40:32You can shift into a new state,
40:35and indeed there's now an accumulation
40:37of evidence indicating that this is
40:39actually how suicide risk works.
40:41So this is a study here, but Tracy Witty.
40:44They've done.
40:45Taxa,
40:45metric analysis with large sample of
40:47suicidal individuals and found that
40:49there was a subgroup of suicidal
40:51individuals who
40:52had very, very high risk for suicide,
40:54and they were categorically
40:56distinct from everybody else.
40:57These results were actually replicated by
40:59team down at Baylor College of Medicine,
41:02with psychiatric inpatients,
41:03and found that.
41:04Among psychiatric inpatients,
41:05there's a small group that was really,
41:07really high risk for suicide and then
41:09everybody else was in a lower risk state.
41:12We've seen this as well.
41:13An epidemiological study.
41:14This is a. Project done better.
41:17Army Stars research team led by Ron Kessler.
41:20What they did was they took a large sample
41:22of soldiers who had been discharged
41:25from psychiatric inpatient care,
41:26used machine learning to split
41:28them up into vent tiles.
41:30And then they looked at they rank
41:32ordered the vent tiles in terms of
41:35overall risk level and then mapped
41:37onto who and where are the suicide
41:40deaths occur and what they found
41:42was that over half of the suicide
41:44deaths occur in the first subgroup.
41:46The 1st event tile.
41:48This is on the left hand side
41:50of the screen and you see the
41:52rest of the 19 vent tiles.
41:54There's not as much difference between
41:56them is a little bit of variability.
41:58Groups two and three or a little
42:00bit higher risk than the others,
42:02but not dramatically so.
42:04So this also suggests that there's
42:06this sort of tipping point.
42:07There's one small subgroup that accounts
42:09for more than half of the suicides,
42:11and then there's everybody else
42:13but the rest of the 95% of the
42:15population now on the right hand side.
42:17This is not hypothetical.
42:19Model where if suicide risk was a continuum,
42:22this sort of unidimensional gradual change
42:25process moving from lower to higher risk.
42:27The graph on the right hand side
42:30is what Kessler should have found.
42:32There should have been the sort of
42:35incremental changes in the probability
42:37of suicide deaths within each ventile,
42:39but that's of course not what they found.
42:43We've since mathematically modeled
42:44suicidal Ideations on a session by
42:47session basis within psychiatric
42:49outpatient psychiatric outpatients,
42:51and what we found was that patients
42:53who had a history of multiple suicide
42:57attempts at the start of treatment,
43:00they had a unique change process that
43:03was characterized by sudden dramatic
43:05Upson Downs in suicidal ideations
43:07on a session to session basis.
43:10It was like a sawtooth pattern.
43:13In that that sawtooth pattern
43:15is consistent with the existence
43:17of two discrete states of risk,
43:18where in essence the patients are
43:21bouncing back and forth between
43:22low and high risk that they're
43:24not doing it in a gross, gradual,
43:26slow manner because there's a tipping point,
43:28and so they can be.
43:30It's sort of like a binary or
43:32a one or a zero.
43:34There is no in between,
43:35and there is a distinct subgroup of patients
43:38who seemed to conform to this change process,
43:40and So what that means is,
43:42I think.
43:43Our traditional ways of thinking
43:45about suicide risk in this sort
43:48of unit dimensional hierarchy,
43:49where at the bottom we have
43:51things like I don't
43:53want to live anymore.
43:55I don't want to be alive,
43:57moving to active suicidal ideations,
43:59moving to planning,
44:00moving to preparatory behavior,
44:02and then at the highest level,
44:04suicidal behavior where there's at least
44:07a significant subgroup of individuals
44:09who do not conform to this pathway.
44:11In this hierarchical model,
44:13some patients do seem to follow
44:15this gradual change process.
44:17But there's another substantial minority.
44:19At the very least,
44:20that don't follow this,
44:22and So what this means is we
44:24probably need to change how we
44:26conceptualize suicide risk.
44:28And so we've now informed
44:30by the notion of emergence,
44:32move towards a 3 dimensional model of suicide
44:35risk and and this figure on the screen.
44:38With this sort of curved claim of
44:40suicide risk is what's referred
44:42to as a cusp catastrophe model.
44:45So this provides us with.
44:47A way to understand why is it
44:49that some individuals seem to
44:51have this gradual change process.
44:53They sort of slowly move through these
44:56incremental stages towards suicide,
44:57whereas other individuals seem to
44:59very suddenly shift from a low
45:02risk state to a high risk state,
45:04and so let me demonstrate several of
45:07the kind of a key change processes here.
45:10This first pathways pathway a.
45:12This is sort of the classic
45:14way of thinking about suicide,
45:16it's unidimensional.
45:16As you move up the surface plane that
45:19corresponds to increasing suicide risk,
45:21and these individuals then follow back down.
45:23They kind of move up and down Hill,
45:26and the way that this typically
45:28manifests is those fluctuations in
45:29suicide rates that have inclined in,
45:31as noted in that,
45:32like very first one of the very first
45:35slides that I've showed you today.
45:37And so we do see that people
45:39have good days and bad days that
45:42they have these fluctuations,
45:43but they tend to be somewhat
45:46smooth and gradual.
45:47These individuals often come
45:48in to mental health care.
45:50We typically diagnosed him with
45:52like mood disorders and this is,
45:54I think the sort of preponderance of
45:56the people that we have traditionally
45:58thought about when it comes to suicide.
46:01We didn't have a different group of
46:03individuals who are located in a
46:05different place on this behavior surface.
46:08They also move up and down Hill,
46:10but because they are located in a
46:12place of the this curved plane that
46:15corresponds to a steeper slope,
46:17they experience much more rapid
46:19increases in rapid decreases in suicide risk.
46:22It's no different than if we were
46:24to kind of like roll a ball up
46:27and down a really steep Hill.
46:29The ball would start to roll up very quickly,
46:32stop, and then come back down very rapidly.
46:35In the steeper the slope,
46:37the faster that return process would be.
46:40Now this this sort of sub group of
46:43individuals seems to characterize
46:45those who are diagnosed with
46:47borderline personality disorder and
46:49have other related conditions that
46:51are characterized by deficient self
46:53regulatory processes where we're
46:55more likely to see a sawtooth pattern
46:58and then one of the key aspects of
47:02this is that that up and down that
47:05dramatic up and down actually increases
47:07their vulnerability for suddenly
47:09shifting from a low risk state.
47:12To a very high risk state from the bottom
47:14of the surface to the top of the surface,
47:17and that was actually what David wrote,
47:19and I found in some of our initial
47:22research with multiple attempters
47:23and we now have a new study we just
47:26published in behaviour research and
47:27therapy in the past year where we
47:30took patient psychiatric out patients
47:31who had attempted 1 one time in their
47:33life and then we mapped out their
47:36fluctuations in suicidal ideations over
47:37therapy and what we found was that the
47:40patients who had larger fluctuations
47:41on a session by session basis.
47:44Or significantly more likely to
47:46attempt suicide during treatment
47:48or soon after treatment.
47:50And so these individuals also,
47:52I think,
47:53are more likely to come in for
47:55mental health treatment.
47:57And so this is where a lot of our
47:59work that Seth mentioned in his
48:02introduction on cognitive behavioral
48:04therapy for suicide prevention,
48:06I think has been really impactful.
48:08I think other treatments in addition
48:10to BTI but also dialectical behavior
48:12therapy has a lot of implications here.
48:15What we were finding is that these
48:17treatments seem to sort of calm the storm
48:20where the fluctuations in suicidal ideations.
48:23Over the course of treatment tend
48:25to settle down so that there is a
48:28decreased probability that a person
48:29will suddenly shift to a high risk
48:32state where suicidal behavior
48:34is more likely to occur.
48:35The key aspect about some of our
48:38findings with BTI is that we see
48:40treatment effects very quickly,
48:42typically within three months
48:43of starting treatment,
48:44and so not only is it a long lasting
48:47effect up to two years post baseline,
48:50but we tend to see pretty early
48:53separation between treatment groups.
48:55Another related intervention
48:56that that we've worked on a lot
48:59as crisis response planning,
49:00which serves as sort of like the kind
49:03of a precursor to safety planning,
49:06which a lot of people are familiar with.
49:09Crisis response planning was,
49:10apart of BTE,
49:11and then we subsequently extracted
49:13this procedure and tested it as a
49:16standalone intervention and emergency
49:17department's as well as walk in clinics
49:20for UNE scheduled crisis evaluations.
49:22Whereas what we do is we hand
49:25write on an index card what?
49:27Ultimately,
49:28amounts to sort of a self regulation plan.
49:30How to know when you're getting upset,
49:33how to know when you're heading uphill.
49:35And then.
49:36Here's a list of things that you can
49:39do to stop yourself from progressing
49:41towards a high risk state into self
49:44regulate to kind of calm yourself back down.
49:46We completed a randomized controlled
49:48trial that we published in 2017
49:51comparing crisis response planning
49:52to treatment as usual and found 76%
49:54reduction in suicide attempts over
49:56the six month follow up period.
49:58And so this.
50:00Very simple.
50:00Ateji that definitely takes 30 or 60 minutes.
50:04We found this actually quite potent
50:06for averting suicidal behaviors.
50:08But then there's one last group that my
50:11research programs increasingly focused on.
50:13This is this pathway.
50:14See, this is the.
50:16This is the performance escape,
50:18the catastrophic change group,
50:19for whom suicidal behaviors
50:21seemed to come out of the blue.
50:23And you can see their position
50:25on the behavior surface here.
50:27What happens with this group is when they
50:30experience an increase in suicide risk.
50:32It's very gradual.
50:33It's not very pronounced,
50:35so maybe they only get to a point where
50:38they're wishing that they weren't.
50:40Around anymore they would.
50:42They think they'd be better off dead,
50:44but in some cases they're not
50:46manifesting active forms of suicidal
50:48ideations or even planning.
50:50But then what happens is they hit
50:52this curve in the behavior surface
50:55and they sort of like teleport up
50:58to the top where they see this very
51:00sudden shift in the probability
51:02for suicidal behavior in these
51:04individuals are much less likely
51:06to come to mental health care,
51:08and it's because for the most part
51:11they're existing in a low risk state.
51:14And so when we say get help,
51:16watch out for these warning signs
51:18of suicide that largely focus
51:19on active suicidal ideations.
51:21It doesn't apply to these individuals.
51:23This isn't the nature of their
51:25subjective experience of suicide risk,
51:26and so we end up missing this group,
51:29and we keep encouraging.
51:30Go get help to get help to get help,
51:33but this is a group for whom that is
51:36a message that just isn't hitting the
51:38target in the way that we needed to.
51:41So we know that about 40 to 50% of those
51:44who attempt suicide sort of skipped.
51:47The planning stage and we have
51:49some newer data coming out.
51:51Showing that manifestations of suicide
51:53risk do not necessarily involve active
51:56thinking about suicide where we are
51:58now able to capture using a scale
52:01called the Suicide cognition scale.
52:03Things like I can't take this anymore.
52:06I deserve to die.
52:07No one can help me solve my problems.
52:11These are perhaps thought processes
52:13that signal this is someone who's
52:16at elevated risk for suicide,
52:18but they aren't necessarily experiencing
52:20suicidal thoughts in the way that we
52:23have traditionally conceptualized them.
52:25Traditionally asked about that,
52:27and so we're effectively missing
52:30a large group of people.
52:33And so this brings me into the kind of
52:35the last idea of what we're working on,
52:38which is the importance of means restriction,
52:41especially with firearm owners.
52:42So now a big portion of my research
52:45is really focused on understanding.
52:47Suicide risk amongst firearm owners
52:49and what we're finding is that there
52:52are really high risk subgroups of
52:54gun owners who they typically own.
52:57Guns for self protection purposes,
52:59but they are much,
53:00much more likely to engage in suicidal
53:03behaviors because we're starting to
53:05see now is that they have a number of
53:09biobehavioral vulnerabilities to suicide.
53:11They view.
53:12The world is a dangerous place.
53:14They perceive hostility and others
53:17actions even with no hostility.
53:19Exists in this seems to degrade
53:21cognitive control processes,
53:22which increases the propensity for them to
53:24engage in these dysregulated behaviors,
53:26and if they have a loaded weapon during
53:28moments of acute distress when they suddenly
53:31shift to a high probability high risk state,
53:34it weaponizes their emotional States
53:36and they die very quickly and we do
53:39not have a way to intervene with them,
53:41and so we do have now a new study.
53:44It's impressed with the American
53:46Journal of Public Health,
53:47that's hopefully will be coming out
53:49in the next few months, showing that.
53:51And we brought gun owners into our lab
53:55and we sat down with them and we talked
53:59about safe gun storage and using gun safes,
54:02trigger locks,
54:03things like that and what we found
54:05was that very simple conversations
54:08guided by motivational interviewing
54:10principles significantly increased
54:11the likelihood of gun owners actually
54:14using safe storage methods which we
54:16know from epidemiological data are
54:18correlated with dramatic reductions
54:20in suicide mortality.
54:22We now have an R61 that we're about
54:24to start enrollment on to further
54:26understand a lot of these processes,
54:29but I think this is in many ways,
54:31one of the most important directions in
54:34suicide prevention is to move outside
54:36of the healthcare system because there
54:38is a subgroup who don't have access,
54:40are not going to seek out mental
54:43health treatment,
54:44and during those moments of a
54:45sudden onset of acute despair,
54:47we just don't have time to find
54:49them in to intervene with them.
54:52So we need to change the environment.
54:55So that we suicide proof their lives in,
54:58decrease the probability of a fatal outcome.
55:03It's all,
55:04so that's that's kind of where we're at.
55:06With the research a lot more
55:09to be done understandably,
55:10but I'm happy to take any questions that
55:13anyone might have in the remaining time,
55:15and likewise,
55:16if you have to drop off,
55:18totally understandable and by all
55:20means feel free to shoot me an email
55:23afterwards with any questions or
55:24follow up thoughts that you might have.
55:27So thank you.
55:30Thanks Greg, if there any questions
55:33folks wanna put them into the chat
55:36chat room that would be great.
55:38Two things I'd never say.
55:39Seeing you give this talk before
55:41Craig so you know two things I
55:43thought were really interesting.
55:44One was on tipping points. You know,
55:46when you think about the medical model of.
55:50Of of that, you presented around suicidality.
55:52This is true, I think,
55:54across many different medical diseases.
55:56So kidney function,
55:57for instance, right?
55:58We learn in medical school that
56:00your kidney function declines
56:01gradually throughout your lifetime,
56:03and then boom,
56:04all of a sudden something happens
56:06and you cross a tipping point,
56:08and then all of a sudden you're
56:11creating starts going up.
56:12You know you're you're essentially
56:14entering kidney failure even
56:15though you've been in decline.
56:17There's been these issues all along.
56:19There's a tipping point.
56:20And same with coronary artery disease
56:23where your things are going on in the
56:25background for an extended period,
56:26sometimes something can happen early.
56:28Maybe you're taking a drug abuse.
56:30Maybe there's another disease
56:31process going on,
56:32but then boom,
56:33all of a sudden there's a myocardial
56:35infarction because something
56:36is occurring in the vessel that
56:38was either an it's similar to
56:39the 3D model you presented,
56:41where it can be gradual or all
56:43of a sudden something can happen
56:45and you just jump up the curve.
56:47So I really like that,
56:48right?
56:50Yeah, it's the notion of tipping
56:52points is yeah, it's widely used.
56:55In other words not widely used,
56:58but it's sort of applicable
57:00and well understood,
57:01and other branches of medicine but
57:04also other Sciences within biology,
57:06chemistry, physics.
57:07All of these processes are quite
57:10widely used in even the notion of
57:13catastrophic change processes.
57:14And so I think there's a lot of potential
57:18value and thinking about change.
57:21In these more complicated ways and
57:22the good news is that we do have a
57:25lot of precedent and a lot of examples
57:27from other scientific disciplines,
57:29and so it's really now just sort of
57:31a matter of applying the methods
57:32in the computational concepts
57:34to the work that we do.
57:37Then there's a question from Tammy.
57:41Say I'll skip over the very nice words
57:43at the beginning of the question,
57:45although everyone can read it,
57:47any data you're aware of Crag that's
57:49been collected with micro longitudinal
57:51methods like EMA or experience
57:52sampling with firearm owners.
57:56So not yet, but that's actually so.
57:58There are 61 that I just received.
58:00We are going to do that this year,
58:03so January is when we're
58:04hoping to start enrollment.
58:05What we'll do is the design of our study will
58:08be bringing gun owners and non gun owners.
58:11And then we're looking at two
58:13different subgroups of gun owners,
58:14those who carry a firearm on a
58:17regular basis and those who do not.
58:19Maybe they have a gun in their house,
58:21but they don't necessarily carry
58:23it with them on a regular basis.
58:26And yeah, we'll be hanging them six
58:29times a day for four weeks to see.
58:32Like what are they doing?
58:33Who are they with will be asked about.
58:36Mood will also be think
58:38about suicidal ideations.
58:39So Needless to say we have a pretty
58:41robust risk management protocol in
58:43place because consultation with
58:45other suicide researchers using MA.
58:47Some of the comments I've heard is,
58:50like you know,
58:51we all know intuitively that probably some
58:53of our participants are carrying a weapon,
58:56but.
58:56This is the first time that you actually
58:59know they'll be carrying a weapon when
59:01they're suicidal and that sort of
59:03changes the scariness of the project,
59:06so we have a pretty robust risk management
59:08protocol in one of the hypothesis we have it.
59:11We will be asking the mini may are
59:14you carrying a firearm right now,
59:16or is there a firearm within?
59:19I can't remember the wording.
59:21Basically,
59:21is there something firearm
59:23within reach something like that?
59:26And one of our hypothesis is
59:28that when someone is in physical
59:30possession of a firearm,
59:32that might increase their
59:35emotional liability.
59:36Their reactivity to stressful events,
59:37so my hope is that maybe maybe
59:40in a couple of years, yeah,
59:42we'll be able to have some of
59:44those those data available.
59:46You know on the group this
59:48is just a question for me.
59:50It's not in the chat box.
59:51And please if anyone has questions,
59:53feel free to jot them down in the box.
59:55But I'm thinking about that
59:57third group on your 3D model.
59:59I've done some work with health.
01:00:00And where they're looking for signals
01:00:02and in non behavioral health claims
01:00:04data so people are not feeling well,
01:00:05they're going to primary care.
01:00:06They are finding flags that seem to be
01:00:08predictive of eventual suicide attempts,
01:00:10even though the people are actually
01:00:11not in any sort of mental health
01:00:13care based on their claims data.
01:00:14Do you have any sense of whether or
01:00:16not I mean have you looked at that?
01:00:18Is that something that's come up
01:00:20as to are there going to be signals
01:00:22that we can acquire to reach out?
01:00:25The so the the one project we did
01:00:28that was not tide to like medical
01:00:31record data was social media project
01:00:34is actually funded by Department
01:00:37of Defense several years ago and we
01:00:41basically content coded a years worth of.
01:00:44It was mostly Facebook posts.
01:00:47Amongst users personnel who died by
01:00:49suicide and then a control group,
01:00:52they died of other non suicide causes
01:00:54and we looked at we kind of compared
01:00:57what was on their social media
01:01:00accounts and one of the findings was,
01:01:02you know we did find a statistically
01:01:05significant higher rate of,
01:01:07you know post that were hopeless
01:01:09and despondent and depressed.
01:01:10And had those types of themes.
01:01:13They were particularly huge
01:01:15effect sizes once we applied.
01:01:17These sort of dynamical systems
01:01:19models what we found was that yeah,
01:01:21that was like a game changer in one of
01:01:24the key findings was that we that was
01:01:27where we started to see the increase
01:01:30in instability in certain variables
01:01:32was a very very clear indicator.
01:01:34And what was interesting is as we got
01:01:37closer and closer to the date of death,
01:01:40those change processes got
01:01:42more and more pronounced.
01:01:43The second key finding was that we
01:01:46found that it was certain sequences.
01:01:48Of variables, so if you had,
01:01:51say variable in variable,
01:01:52feed if variable a consistently
01:01:54happened right before variable
01:01:56B that signaled suicide.
01:01:57But if variable B came
01:01:59right before variable A,
01:02:01it did not signal suicide.
01:02:03So that sort of notion of
01:02:05sequencing ended up being really,
01:02:07really key and then an independent
01:02:09team led by Glenn Coppersmith and
01:02:11they actually used the technique
01:02:13faceoffs presented at a conference.
01:02:15They went back to use it on Twitter data,
01:02:19and they called it Micro patterns,
01:02:21and they found that.
01:02:22These micro patterns of sequencing in
01:02:25certain orders doubled the amount of
01:02:27information and predictive ability
01:02:29to identify not only suicide but
01:02:31also like schizophrenia, anxiety,
01:02:33depression.
01:02:33So we have
01:02:35two questions. Actually,
01:02:36I think related to your EPI scenario,
01:02:38so I'll jump to those real quick.
01:02:42Alec was asking about the dependent variable.
01:02:45Do any of the conclusions you have
01:02:47presented applied differently according
01:02:48to whether we're looking at attempts
01:02:50that could have ended in death?
01:02:54Yeah, so we've not gotten to
01:02:56that point yet because our
01:02:58samples haven't been big enough.
01:03:00We do have some studies
01:03:02where death was the outcome.
01:03:04We have studies where attempts were
01:03:07the outcomes and so the general
01:03:09concept seemed to be the same,
01:03:12but I think the question is well
01:03:14placed in it is something that I've
01:03:16wondered about is are are there
01:03:19differences between highly lethal and
01:03:21less lethal suicidal behaviors that?
01:03:24Yeah, sort of those.
01:03:26Those sudden shifts to high risk
01:03:28states we see at least are thinking
01:03:31right now is perhaps more relevant
01:03:34for things like firearm suicide
01:03:37and other highly lethal methods.
01:03:39Whereas pathways A&B,
01:03:41those are individuals who tend to select
01:03:44less lethal methods like medications,
01:03:46and so there may actually be
01:03:49different change processes that signal
01:03:51lethal versus non lethal outcomes.
01:03:53I would love to.
01:03:55Hopefully get a data set
01:03:57large enough where we can
01:03:59test that out more.
01:04:00Yeah, one of the things I loved about
01:04:03your work is to focus on attempts,
01:04:06which is like heart attacks, right?
01:04:08It potentially lethal,
01:04:09and it relates to Alex,
01:04:10question around that.
01:04:11And then Sally asked about alcohol
01:04:14consumption and whether or not that
01:04:16teleports someone to severe risk.
01:04:19Yeah, yeah, that's that's a great question,
01:04:22and that's that's something
01:04:24that we wondered about as well.
01:04:27We don't know for sure, but you know,
01:04:31so there's some evidence outside of
01:04:33the suicide field that acute alcohol
01:04:37intoxication perhaps attenuates.
01:04:38Fluctuations in suicide risk owns a
01:04:40person down and oftentimes a sort of
01:04:42the motive for alcohol consumption.
01:04:43As I'm up and down,
01:04:45I kind of feel out of control.
01:04:48So I drink alcohol and it numbs
01:04:50and sort of pegs these Upson
01:04:52downs that they're less extreme.
01:04:54But then there are other individuals
01:04:56for whom alcohol consumption sort of.
01:04:58Yeah, sort of ramps them up and make some
01:05:01more vulnerable to these sudden shifts.
01:05:03So we will be we.
01:05:05That's one of the other things
01:05:07we are going to look at.
01:05:09Some of our PMA studies is how does
01:05:11acute alcohol consumption intoxication
01:05:13perhaps alter change processes?
01:05:15My suspicion what I really think
01:05:17we'll probably find is that
01:05:19there is going to be sort of a.
01:05:22A conditional finding where it
01:05:24will be some for some people.
01:05:28Alcohol consumption and those sort of
01:05:30calm them down and then for others
01:05:33it increases their reactivity,
01:05:35which I think would be really helpful
01:05:38because that might help us to more
01:05:41accurately target different subgroups
01:05:42of patients and individuals for alcohol
01:05:45consumption within their treatment plans.
01:05:50There's another question that
01:05:51came in between those two,
01:05:53but it wasn't as related to what
01:05:55you had said, so I hold it back,
01:05:58which is the international
01:06:00variability safe to countries.
01:06:01I think she meant the country Australia.
01:06:04Where they ban access to firearms
01:06:06in a more stringent way?
01:06:08Can you comment on that?
01:06:10Yeah, so there certainly are.
01:06:13You know, lower suicide rates and.
01:06:17In countries with more
01:06:18stringent access to firearms,
01:06:20what one of the things that related
01:06:22to this when we look at just sort of
01:06:25means restriction in general is that
01:06:27there are sort of international and
01:06:29cultural variability regarding this,
01:06:30and so one of the key assumptions about
01:06:33means restriction in general that we
01:06:35talk about is that the method that
01:06:37you're going to restrict needs to be
01:06:40sufficiently lethal to have an effect,
01:06:42so it has it has to kill people with
01:06:44a high enough rate that restricting
01:06:46access will actually make a difference.
01:06:49And then Secondly,
01:06:50the method has to be common enough
01:06:53within the population that again
01:06:55restricting it would potentially
01:06:57reduce an observable notable,
01:07:00meaningful proportion of the population.
01:07:02And so yeah,
01:07:03in many international spaces
01:07:05in other nations,
01:07:06firearms isn't really sort of initiative.
01:07:09Are no firearm suicides are
01:07:11very little because of their
01:07:14limited access to that method,
01:07:16but in those nations they typically look at.
01:07:20Other methods in from a means
01:07:22restriction perspective.
01:07:23They would target something else so.
01:07:26The most classic examples of this
01:07:29historically was in Sri Lanka,
01:07:31Indonesia or maybe it was Indonesia
01:07:34and some other Pacific island nations.
01:07:37It was poisoning with fertilizer.
01:07:40Someo farmers would drink there.
01:07:42Basically fertilizer to kill themselves in.
01:07:45So in these nations they restricted
01:07:48basically the sale of pesticides and
01:07:51fertilizers that that removed some of
01:07:54the most toxic chemicals and agents and so.
01:07:58In essence, former still had the tools
01:08:01that they need to do their jobs,
01:08:04but now they were less dangerous and
01:08:07so if they drink pesticide or whatnot,
01:08:10they were less likely to die as a result.
01:08:14In UK it was carbon monoxide
01:08:17being sent to homes to fuel ovens,
01:08:20things like that,
01:08:21and some of the Scandinavian
01:08:23nations is restricting paracetamol.
01:08:26And so,
01:08:27so in the United States,
01:08:28it's guns and I don't think will ever
01:08:31been the curve on suicide until we
01:08:34start really thinking about firearms as
01:08:36a key central aspect of a conference.
01:08:39Is suicide prevention plan.
01:08:43Um, we have a very long statement
01:08:45in question from Shelly.
01:08:47I don't know if she wants to
01:08:50actually go on audio and say it.
01:08:53I mean, I think.
01:08:55Well, that's thought about just
01:08:57sort of a question comment crag
01:08:59because when I think about some of
01:09:01the questions in the talking about
01:09:03because 'cause this shell is question
01:09:05comment was really around a bunch
01:09:07of linear variables and then some
01:09:08unpredictable variable or exponential.
01:09:10I think you know comes in from
01:09:12some direction and then pushes
01:09:14everything over the tipping point.
01:09:15But I think on the treatment side
01:09:17or intervention side one of the
01:09:19things that I find interesting.
01:09:21If you take time to really think about.
01:09:24Crisis response planning.
01:09:26CBT in your work.
01:09:28In some ways,
01:09:29it helps neutralize the unpredictability
01:09:31of what those things are.
01:09:34Because you're identifying
01:09:35specific things that will either
01:09:38distract or soothe the storm.
01:09:40You know that are not 100% likely,
01:09:42but at least are highly likely,
01:09:44and so some of that is in the crisis
01:09:46response plan some more of it is in
01:09:48the CBT in terms of better identifying
01:09:50when those storms are brewing.
01:09:52But can you comment on that?
01:09:54Like why is it so effective?
01:09:57Yeah, I think it's you.
01:10:01So it doesn't sort of like provides
01:10:03this sort of buffer zone between these
01:10:05two distinct States and so in essence,
01:10:08the first piece of it is how to
01:10:10know when you're heading towards
01:10:12a higher state and being able to
01:10:15recognize your own personal indicators
01:10:17or warning signs of that process,
01:10:19and then so now that you're aware of,
01:10:22like Now you know that you're
01:10:24heading towards that space,
01:10:25then the rest of the plan is all about.
01:10:29Here's a whole bunch of
01:10:30different things that you could.
01:10:32Do to report back up to reverse the
01:10:36process to take an offering up to.
01:10:38In essence,
01:10:39lots of lots of different ways to avert
01:10:42getting into that high risk space,
01:10:45and so in some cases,
01:10:47and it really is sort of riding the wave,
01:10:51but it does.
01:10:52It's something that I think really hits
01:10:54that notion of non proportionality
01:10:56is something very simple,
01:10:58like I was shocked to be perfectly
01:11:01honest when we did that CRP study.
01:11:05I was like, you know, this.
01:11:06We're writing a bunch of stuff
01:11:08done on an index card.
01:11:09In about 30 minutes,
01:11:10you know this is going to help in
01:11:13the next few weeks, but you know,
01:11:15we really need to get someone into
01:11:17like treatment like the CBT or
01:11:19something like that to have a longer
01:11:21term effect and what we ended up
01:11:23finding was that the effects tended to
01:11:25get bigger and bigger as more time passed,
01:11:28and so I was like wow,
01:11:29there's something happening here and
01:11:31it appears to help individuals to
01:11:33know where their tipping point is.
01:11:35Into in essence,
01:11:37a stay away from that,
01:11:39and it seems to work very,
01:11:41very effectively as result.
01:11:44So I think we're how we have 60 seconds left,
01:11:47so just given all this data,
01:11:49what do you think? Why?
01:11:51Why do we still have these
01:11:53issues in the military,
01:11:54the VA and in our country?
01:11:56What's preventing these interventions from?
01:11:59And be part of it is.
01:12:01I think we still buy and larger than the
01:12:04middle health disciplines conceptualize
01:12:06suicide as a symptom of mental illness.
01:12:09And so by and large treatment, as usual,
01:12:12is largely treat the depression.
01:12:14Treat the PTS di treat anxiety,
01:12:16whatever the you know,
01:12:18whatever the diagnosis is,
01:12:20and then theoretically suicide
01:12:21risk should resolve after that.
01:12:23But now I think we increasingly recognize
01:12:26that suicide is transdiagnostic
01:12:27that it's better to look at.
01:12:30Suicide risk is.
01:12:31Independent of psychiatric diagnosis
01:12:34and so treatments like bteen crisis
01:12:37response planning are going directly at.
01:12:40Several mechanisms that seem
01:12:42to give rise to suicide risk,
01:12:44and so it's a more direct targeting
01:12:46of the problem as opposed to an
01:12:49indirect targeting through these
01:12:51other reported mental health.
01:12:53Channels the last thing that I think
01:12:55is really key that another aspect of
01:12:58my thinking is really moving out of
01:13:01this sort of mental health model of suicide,
01:13:04and we're now looking more and
01:13:06more at more like environmental.
01:13:09Injury prevention models where
01:13:10you know we don't reduce traffic
01:13:12fatalities by saying everyone needs to.
01:13:14Lookout for the warning signs of
01:13:16a car accident and then if you see
01:13:19those warning signs you should go
01:13:21and get enroll in a drivers Ed class.
01:13:24I mean,
01:13:25that's basically how we approach
01:13:26suicide prevention right now.
01:13:28What we do is we build safer
01:13:30roads and we build safer cars and
01:13:33we require people to buckle up.
01:13:35And we criminalize conditions like
01:13:37drinking and driving that increase
01:13:39the probability of fatal outcomes.
01:13:40And so,
01:13:41how do we now take a similar
01:13:44thought process with suicide,
01:13:46where we change the environment in a
01:13:49way that reduces the likelihood of a
01:13:52person if they do shift to a high risk state,
01:13:56they have a seat belt now and they
01:13:59are significantly more likely
01:14:01to survive that unforeseen,
01:14:03unpredictable conditions.
01:14:04So
01:14:05can you one quick thing on that
01:14:07that issue of of the systemic?
01:14:10Approach and associating
01:14:11it with mental illness.
01:14:13There's varying degrees in different
01:14:15studies about how many people actually
01:14:17even have an independent mental health
01:14:19condition from suicidality, right?
01:14:21Just like heart attacks like some
01:14:23people just don't have another
01:14:25cardiac condition that we're aware of.
01:14:28So what is your best guestimate of the
01:14:30people who attempt suicide and actually
01:14:33don't have some other standalone
01:14:35health condition?
01:14:36Yeah, I would say so.
01:14:38It's a bigger percentage than we think.
01:14:41Or at least that we've traditionally assumed.
01:14:43So if you look at CDC data,
01:14:4555% of suicide decedents in the US
01:14:47do not have a known mental illness.
01:14:49Now the typical worst retort to that is,
01:14:51well, they didn't go in to meet
01:14:53with the therapist or psychiatrist,
01:14:55and so they were never diagnosed,
01:14:57so we just didn't know that they had
01:14:59the condition that we assume is there.
01:15:02But if you look at some
01:15:03other lines of data and ones,
01:15:05I think that is really informative.
01:15:07This Joe Franklin's meta
01:15:08analysis from a few years ago.
01:15:10Looking at 50 years of
01:15:12suicide risk factor research,
01:15:13if you kind of do some reverse engineering
01:15:16of some of the statistics he reported,
01:15:18in essence,
01:15:19what his data would suggest is that.
01:15:21Somewhere around 40% of those
01:15:24who attempt suicide or die by
01:15:26suicide have a mental health
01:15:29diagnosis or elevated symptoms.
01:15:30Things like that.
01:15:34I think the third line of evidence
01:15:36comes from psych autopsy studies,
01:15:38which are often used to support that.
01:15:40This is where the 90% status
01:15:42obtained from 90% of suicide
01:15:44decisions have a mental illness.
01:15:46It comes from cycle autopsy studies.
01:15:50The second party method is
01:15:52highly vulnerable to bias,
01:15:54and if you look at case controlled
01:15:56cycle top studies where you can see
01:16:00is that they generally overestimate
01:16:02rates of psychiatric illness in
01:16:04control cases by double and so you
01:16:07can reasonably infer that maybe
01:16:09psych autopsies are doubling their
01:16:12biased towards over diagnosing mental
01:16:14health conditions by a factor of two,
01:16:17in which case 90% of.
01:16:20Which is their finding would convert to
01:16:22about a 45% and estimate the correction,
01:16:25so to speak.
01:16:26So this is sort of like these several
01:16:29lines of evidence that I would say
01:16:32maybe around 40 to 50% of suicide.
01:16:35Decedents Oregon suicide
01:16:37attempters probably do not have.
01:16:39A diagnosable mental condition.
01:16:41They might be really stressed out.
01:16:43It might be really upset
01:16:44under pressure for sure,
01:16:46but come on like being upset
01:16:48when your partner tells you that
01:16:50they're going to leave you there.
01:16:52Having an affair is not a mental illness.
01:16:54That is a normative emotional
01:16:56reaction to a life stressor,
01:16:58and so I think we've blurred
01:17:00the lines between.
01:17:01Between these experiences and as a result,
01:17:04we put all of our eggs into
01:17:06the Git mental health.
01:17:08Basket mental health treatment basket
01:17:10and so we're ignoring a lot of other
01:17:14potentially useful and impactful
01:17:17suicide prevention strategies.
01:17:21Some very positive feedback in the chat.
01:17:22I'll take some screenshots so
01:17:24that you can show it to your loved
01:17:27ones and family so that they know
01:17:29what a great job you did crag.
01:17:31Any other questions or comments for Crag?
01:17:35Before we let him get on
01:17:37to his weekend I guess.
01:17:41Hi this is Shelly I guess I I apologize
01:17:43for the length the set up there so I've
01:17:45read Malcolm Gladwell's tipping point.
01:17:47Understand I've done a lot of work in the
01:17:49chemistry lab with pH buffering and it's
01:17:51very very simple to overshoot because
01:17:52you're on an exponential pathway right?
01:17:54So what I was thinking is it sounds like
01:17:56you have a lot of linear factors and then
01:17:59you have an exponential factor that may not
01:18:01be the same exponential factor every time.
01:18:03So very very quick to overshoot
01:18:05at that moment of suicidality.
01:18:06Most of the work I do is
01:18:08with veterans at this point.
01:18:10And most of the veterans are very,
01:18:12very familiar with weapons.
01:18:13The conversations I start out early I
01:18:15start out often talking about guns.
01:18:16I talked extensively about it
01:18:17in the interview,
01:18:18find out how they're stored,
01:18:20what they do with somehow they carry it.
01:18:22You know,
01:18:22there's a fairly lengthy conversation
01:18:24and a lot of times sometimes they
01:18:25back off and sometimes it it goes to.
01:18:27You know, I just say listen,
01:18:29you're probably not anything
01:18:30to worry about right now,
01:18:31but if the time ever comes in the future,
01:18:34I want to, you know,
01:18:35I have a comfort level talking
01:18:37with you about this,
01:18:38and we've laid out the groundwork for that.
01:18:40Now I don't have any data.
01:18:42I don't know if it helps us.
01:18:44Don't know if it doesn't,
01:18:45but one of the frustrations I have
01:18:47is with my fellow clinician who
01:18:49sometimes in all best efforts.
01:18:51Seem like that conversation
01:18:52is incredibly minimal,
01:18:54is sort of the richness that
01:18:56it could be done.
01:18:57Yeah,
01:18:58so I guess I'm wondering what we
01:19:00can do to train the clinician to
01:19:03inquire in a way that's useful
01:19:05to the patient in those times.
01:19:08So we yeah,
01:19:09so we trained clinicians pretty
01:19:10often in mean safety counseling,
01:19:13but now the training workshop that I do,
01:19:16I just call firearm safety counseling.
01:19:18I'm like, yeah,
01:19:19'cause I find clinicians are usually
01:19:21reasonably comfortable talking about like.
01:19:23Limiting access to medications
01:19:25and things like that,
01:19:26but it is a firearm issue that often is much,
01:19:30much more challenging, and so we do.
01:19:33So we do have data.
01:19:35Their forthcoming that if you do this,
01:19:38if you have these conversations in
01:19:40a very sort of non judgmental way.
01:19:43But again we used the motivational
01:19:45interviewing based approach we found.
01:19:47There was incredibly highly
01:19:49acceptable in our study with military
01:19:52personnel out of 200 year old 130.
01:19:54200% of them said I would recommend
01:19:56this conversation for a friend,
01:19:58which is sort of like OK then.
01:20:01That's some St cred there.
01:20:02This is evidence of acceptability.
01:20:06Reached their likelihood of locking up their
01:20:08guns and we found that the vast majority,
01:20:11even though there was there,
01:20:13was a small number who kind of still had,
01:20:15you know, screw you guys at
01:20:17the end of the conversation,
01:20:19all of those during the follow up.
01:20:21They said, you know,
01:20:22I felt respected and listened to you guys
01:20:25didn't push me and so we had a few who
01:20:28at least we're left with a good impression,
01:20:30even though perhaps we hadn't yet convinced
01:20:32them that it was in their best interest.
01:20:35But one of those things that we
01:20:37have found really helpful working.
01:20:39Gun owners in general.
01:20:40Is using the metaphor of a designated
01:20:42drivers in wearing seatbelts and
01:20:44we say do you when you drive?
01:20:46Do you only wear seat belt on the day that
01:20:49you expect to get into a car accident?
01:20:51And they're like, well, no,
01:20:52you can't predict it is like right?
01:20:54And we never know when we're going to
01:20:56have those really, really bad days.
01:20:58And so that's why we wear a
01:21:00seat belt just in case.
01:21:02And so what's going to be
01:21:03the seat belt for your gun?
01:21:05And they find that we were finding
01:21:07that oftentimes helps him to think.
01:21:09OK,
01:21:09maybe a gun safe and unlock something
01:21:11like that is sort of like a seat belt.
01:21:14And that might be the difference
01:21:15between life and death in the same way
01:21:18that wearing your seat belt can be.
01:21:19Those difference between life and death
01:21:21in a car accident and then the designated
01:21:23driver model is really resonated a lot.
01:21:25Where,
01:21:26like you know,
01:21:26if you're worried about a friend,
01:21:28we we target this sort of community rather
01:21:30than this like a high risk individual,
01:21:32but will say you know when
01:21:34your friend has been drinking,
01:21:35you take away their parties because
01:21:37it's dangerous and it doesn't mean they
01:21:39never get to drive again in their life.
01:21:41It's just that you have to wait
01:21:43until they're sober so it's
01:21:45safer and then they can.
01:21:46You know,
01:21:47have a car keys back again and so
01:21:49it works the same with the gun,
01:21:51shouldn't it will ask you should
01:21:53suicidal people have access to
01:21:54loaded weapons and everyone's like,
01:21:56no, that's a terrible idea,
01:21:57like right,
01:21:58and so if you're if you know we have a friend
01:22:01is going through a hard time like that.
01:22:04Let's think about this like a
01:22:05designated driver and let's maybe
01:22:07offer to temporarily hold onto
01:22:08their weapons until they're in
01:22:10a different state of mountain.
01:22:11And then perhaps it would be
01:22:13safer for them to have access.
01:22:15And we're finding those messages
01:22:17are very positively received.
01:22:18But the hard part is,
01:22:20yeah,
01:22:21training clinicians.
01:22:21My sense is that clinicians are often
01:22:25biased towards complete removal.
01:22:27Of the fire room.
01:22:28From the households which makes
01:22:30a lot of sense,
01:22:31that is definitely a probably
01:22:33the safest option,
01:22:34but we're really taking more of a
01:22:37harm reduction approach and saying,
01:22:39all things being equal,
01:22:40if someone has multiple loaded weapons
01:22:43that are readily available in the home
01:22:45and we move them to a state where now
01:22:48those weapons are all in a gun safe,
01:22:51or they're all locked up with a trigger lock,
01:22:54even though they're still in the home.
01:22:58They are in a safer space,
01:23:00relatively relatively speaking
01:23:01than they were before,
01:23:03and I see that as a valuable
01:23:06movement that's worth us talking
01:23:08with this clinicians.
01:23:09While I see Mike and Alec and Howard here,
01:23:13you have three, you know,
01:23:15preeminent forensic psychiatrists.
01:23:16And I heard what you said about
01:23:19absolute removal of the gun,
01:23:21which my suspicion is done out of fear of
01:23:25liability for not insisting on it versus.
01:23:28Google clinical evidence 'cause
01:23:30your middle ground is so
01:23:31intuitive and makes so much sense.
01:23:33You know my suspicion,
01:23:34and I am always have a little
01:23:36little touch of cynicism,
01:23:37and I guess my perspective on things
01:23:39is that it's because we don't go for
01:23:41the absolute removal were afraid.
01:23:42If something happens,
01:23:43there's a liability risk.
01:23:44It's black or white.
01:23:46And I remember the first time
01:23:48I I saw you speak live,
01:23:50you put up a little table of like the disk,
01:23:53disjoint between the misalignment
01:23:55between what does the clinician want
01:23:57when they meet with the suicidal patient?
01:23:59And what does the patient want?
01:24:01Do you remember that slide?
01:24:03That was quite awhile ago?
01:24:05Comment on that because I thought it
01:24:07was really incredibly elegant, yeah?
01:24:11Yeah, it's sort of a key point in a
01:24:13lot of the trainings I do is yeah
01:24:15this that the clinicians goals are
01:24:18to prevent the patient from dying,
01:24:20and then I also tongue in cheek,
01:24:22say and to avoid getting sued.
01:24:24And then I like to say well in
01:24:26most cases let's be honest,
01:24:28we don't want to get sued and we know
01:24:30the way to not get sued is to not have
01:24:33a patient die something like that.
01:24:36Whereas the patient's goals are
01:24:37to alleviate their suffering
01:24:38and solve their problem,
01:24:40and So what ends up happening is we.
01:24:43Sometimes gets so focused on preventing
01:24:45death that we forget that in another
01:24:48important part of suicide prevention is
01:24:51creating lives that are worth living,
01:24:53and so we may succeed in the short term in
01:24:56keeping someone breathing biologically alive.
01:24:59But if we don't do something
01:25:02that changes their environment,
01:25:04their psychology,
01:25:04things like that,
01:25:06and probably they're going to get
01:25:08into the state again,
01:25:10and so we need to look at quality
01:25:13of life in addition to simply just.
01:25:17Like restraining people from dying,
01:25:19and so when it comes to the issues
01:25:21surrounding like means restriction,
01:25:23I think of you know I've written
01:25:26about this a few times.
01:25:27I think one of the downsides we
01:25:29recommended as a suicide prevention
01:25:31intervention for clinicians.
01:25:33But as was Shelley,
01:25:34was alluding to we don't really
01:25:37do any training at all on how
01:25:39to do this effectively,
01:25:40so we almost set ourselves up for failure,
01:25:43and we think I think in terms of
01:25:46these sort of binary extremes.
01:25:49Where I don't know.
01:25:50We'll see how things emerge overtime.
01:25:52You know I do some consulting on
01:25:54legal cases like negligence cases,
01:25:56things like this and it's a topic
01:25:58that is very key to a lot of those
01:26:01is at what point do you say that a
01:26:04clinician have been reasonable and
01:26:06done enough 'cause we can always
01:26:08find something more that a person
01:26:11could have theoretically done?
01:26:13And it I found it tough with the gun issue,
01:26:16but they give some cases now.
01:26:18Clinicians that actually did
01:26:20needs restriction.
01:26:21Yeah,
01:26:21they didn't need description and
01:26:23then the patient didn't tell them
01:26:25they still had a secret gun.
01:26:27I mean it's good news.
01:26:29Craig is that unlike drinking and driving
01:26:31gun ownership is not not all politicized.
01:26:34So since drinking and driving and
01:26:36designated driver that just simple,
01:26:38it's just simple problem.
01:26:40The gun issue I'm sure will
01:26:43be even easier to tackle.
01:26:45Yeah, well thank you, anything else?
01:26:48I just wonder what you think
01:26:50the APA is considering having
01:26:53suicidal behaviors, a diagnosis.
01:26:56And given the fact that yeah don't have,
01:26:59I just wonder what you think about that.
01:27:03Yeah, I'm sort of ambivalent about it.
01:27:06On the one hand.
01:27:08I think some of the arguments being
01:27:11made for why we want to do it,
01:27:14I think makes sense.
01:27:16You know to recognize it as being discrete
01:27:19from other psychiatric conditions diagnosis,
01:27:22I think probably there might be what?
01:27:27Joyner is called the closet with an acute
01:27:30suicidal syndrome or something like that,
01:27:32where maybe there is kind of a
01:27:34unique mental state associated
01:27:36with near term risk for suicide.
01:27:38Now the downside kind of my hesitation
01:27:41about it as I kind of feel like begin
01:27:44were now now with a diagnosis as
01:27:47opposed to a manner of death. And.
01:27:50You know, I don't know that we have like,
01:27:53yeah, Heart Attack syndrome.
01:27:54We don't.
01:27:54You know, it's sort of.
01:27:56I kind of feel like it's our continuing trend
01:27:59to conceptualize and think about suicide.
01:28:02From the nearly exclusive
01:28:03lens of psychiatric illness.
01:28:05And so I think that will slow
01:28:07us down from in my opinion.
01:28:09I think we need to be a little bit
01:28:12more divergent and are thinking
01:28:14about suicide to consider it from
01:28:16these different perspectives and
01:28:18angles as opposed to continuing to
01:28:20kind of narrow us down more and
01:28:23more into the DSM and the domain of.
01:28:26You know one particular health
01:28:28care discipline so.
01:28:32And no one is asking me,
01:28:33but I happen to the heart attack
01:28:35thing to me or an arrhythmia is
01:28:37in fact a parallel in my mind.
01:28:39Anyone can have.
01:28:40I honestly believe anyone can
01:28:41become suicidal with the right.
01:28:43External variables,
01:28:44and certainly if other conditions
01:28:45occur as they go through life,
01:28:47just like in a heart attack,
01:28:49anyone can get Melanoma.
01:28:51They are like important,
01:28:52they had outcomes,
01:28:53and I wouldn't worry about it, Craig.
01:28:55Yeah, well and I think yeah,
01:28:57I've thought about this a lot in
01:28:59the past year when they were getting
01:29:02close to a year of a pandemic.
01:29:04And so I'm constantly asked
01:29:06about how the pandemic influence
01:29:08suicide risk and how do we improve
01:29:10access to mental health care.
01:29:11And I think the point that.
01:29:14We often overlook is like, yeah,
01:29:16you know, therapy medications might
01:29:17help to reduce a person's distress,
01:29:20but it doesn't inherently change the
01:29:22fact that the environment right now is
01:29:25placing a lot of strain on individual,
01:29:27so you can't therapy your way out of
01:29:30COVID-19 you know you can't therapy
01:29:32your way out of a minimum wage job.
01:29:35You can't therapy your way out of an abusive,
01:29:38toxic work environment.
01:29:40And and so I think this is.
01:29:43This is one of the main reasons why
01:29:46I think we're so bad that suicide
01:29:49prevention as there are things in
01:29:52life that contribute to suicide risk.
01:29:55But we we largely think about suicide
01:29:57as being within the individual.
01:29:59The thing that we.
01:30:00Just to sort of root out and get rid of
01:30:04when in reality there are conditions
01:30:06all around us that contribute to that,
01:30:09and we would probably actually
01:30:11see way better results if.
01:30:13If we increase the minimum wage,
01:30:15if we expanded access to health care,
01:30:18if we targeted racism and discrimination
01:30:20against vulnerable populations,
01:30:21and there's not much that I'm going to
01:30:23be able to do as a health care provider.
01:30:26Yeah,
01:30:27to improve the financial stability
01:30:28of my patients that they're working
01:30:303 minimum wage jobs.
01:30:32It's it would be way more impactful to
01:30:34just increase their salary in resolve.
01:30:36A lot of the stress that they're coming in.
01:30:39Complaining to me about.
01:30:41But of course,
01:30:42it's really not coming to complain.
01:30:44About that because I can't afford it, right?
01:30:47So anyway.
01:30:51Craig, thank you.