>> THANK YOU VERY MUCH FOR COMING HERE TODAY. I THINK IT'S ABOUT TIME TO START. I KNOW IT'S HARD TO GET THROUGH SECURITY. WE HAVE BEEN WAITING FOR A LITTLE BIT LONGER. YOU WON'T HEAR VERY MUCH FROM ME TODAY. WE HAVE A STELLAR PANEL OF SPEAKERS AND VERY FORTUNATE TO HAVE THEM TALK TO US TODAY. APART FROM THANKING OUR WONDERFUL SPEAKERS, WHICH I WILL DO ALSO AGAIN LATER ON, I WOULD LIKE TO THANK THE INSTITUTION, THE NATIONAL INSTITUTE OF MENTAL HEALTH FOR THE OPPORTUNITY DO HAVE THIS WORKSHOP TODAY. LESSONS THAT MANY OF US HAVE ENCOUNTERED IN OUR PROFESSIONAL LIVES. SOME OF US WILL HAVE ALSO COME ACROSS IT IN A MORE PERSONAL CAPACITY. IT IS VERY SALIENT BOTH FOR A PUBLIC HEALTH PERSPECTIVE AND FOR PEOPLE INDIVIDUALLY. I'M PARTICULARLY GRATEFUL TO DR. MARYLAND PAO, OUR CLINICAL DIRECTOR, WHO HAS ENABLED THIS TO HAPPEN TODAY AND FOR HER ONGOING SUPPORT. I'M ALSO GRATEFUL TO MY COLLEAGUE, DR. TOBIN, WITH WHOM AND VERY GRATEFUL TO PEOPLE IN MY BRANCH, FOR FACILITATING FREEDOM TO ORGANIZE SUCH AN EVENT. AND OF COURSE OUR GROUP, THE MOOD BRAIN AND DEVELOPMENT UNIT THAT DOES RESEARCH IN DEPRESSION AND RELATED CONDITIONS SUCH AS SUICIDE HERE AT THE NATIONAL INSTITUTE OF MENTAL HEALTH. THANK YOU VERY MUCH. ALLOW ME TO INTRODUCE DR. DR. MARYLAND PAO WHO IS OUR CLINICAL DIRECTOR HERE AT THE NIMH. A CLINICIAN WITH LONGSTANDING EXPERIENCE IN TREATING YOUNG PEOPLE WITH MENTAL HEALTH PROBLEMS. WORKS AT THE INTERFACE OF PHYSICAL HEALTH PROBLEMS AND MENTAL HEALTH PROBLEMS, AN AREA WHERE ADOLESCENT AND CHILD SELF HARM AND SUICIDE ARE PREVALENT AND VERY IMPORTANT. AND IS ALSO THE DEPUTY SCIENTIFIC DIRECTOR. SHE IS A CHILD ADOLESCENT PSYCHIATRIST, A WONDERFUL THING, FOR THE INSTITUTION AND ALSO FOR THE DISCIPLINE AS A WHOLE. SO WE ARE VERY GRATEFUL FOR HER& FOR HER SUPPORT TODAY. [ APPLAUSE ] JUST CHECKING ON THE HOUSEKEEPING ITEMS REGARDING CEUs AND PARKING AND ALL THAT BUT THEY'LL DO THAT SHORTLY. SO, WELCOME. WE ARE VERY PLEASED TO BE OPEN FOR BUSINESS TODAY AND TO BE ABLE TO PRESENT THIS WORKSHOP TO YOU ON ADOLESCENT SUICIDE PREVENTION, RECOGNIZING TEENS AT RISK AND RESPONDING EFFECTIVELY. ARGYRIS STRINGARIS HAS PUT TOGETHER AN OUTSTANDING PANEL OF EXPERTS TODAY TO DISCUSS THE NEUROBIOLOGY OF SUICIDE, SCREENING FOR RISK OF SUICIDE, CLINICAL ASSESSMENT AND MANAGEMENT OF SUICIDAL YOUTH, CURRENT RESEARCH STRATEGIES AND PAINFULLY WHAT HAPPENS WHEN WE MISS THE SIGNS AND SYMPTOMS LEADING TO A SUICIDE. IMPORTANTLY, THIS MEETING IS ABOUT LEARNING HOW WE CAN COME TOGETHER AND SAVE LIVES THROUGH EDUCATION, RESEARCH AND ADVOCACY. EVERY DAY, 118 SUICIDE OCCUR IN THE UNITED STATES, INCLUDING 15 YOUTH, AGES 10-24 YEARS. WE SEE IN OUR OWN BACKYARD SUICIDE OCCURRING IN OUR LOCAL HIGH SCHOOLS. WE MUST PREVENT THESE TRAGEDIES FROM OCCURRING. AS A CLINICIAN, I HAVE BEEN TRACKING YOUTH SUICIDE RATES SINCE THE 1980S AND THEY CONTINUE TO TREND IN THE WRONG DIRECTION OCCURRING IN YOUNGER AND YOUNGER CHILDREN AS YOUNG AS 8. THIS IS CLEARLY A MAJOR PUBLIC HEALTH THREAT FOR YOUTH TODAY. SINCE MY DAYS AS A CHILD PSYCHIATRY RESIDENT, I HAVE ALSO BEEN TRACKING THE WORK OF DR. DAVID BRENT, OUR KEYNOTE SPEAKER THIS MORNING. HIS PIONEERING WORK IN YOUTH SUICIDE RESEARCH IS WELL-KNOWN TO OUR FIELD AND NIMH, WHERE HE IS CURRENTLY SERVING ON THE NATIONAL ADVISORY MENTAL HEALTH COUNCIL FOR DR. GORDON. DR. BRENT IS CURRENTLY THE ACADEMIC CHIEF OF CHILD AND ADOLESCENT PSYCHIATRY AT THE UNIVERSITY OF PITTSBURGH SCHOOL OF MEDICINE, DEPARTMENT OF PSYCHIATRY, WHERE HE HOLDS AN UNDO YOU DO CHAIR IN SUICIDE STUDIES AND DIRECTS SERVICES FOR TEENS AT RISK. SUICIDE PREVENTION PROGRAM FOR CHILDREN AND ADOLESCENTS. HE TRAINED IN PEDIATRICS AT THE UNIVERSITY OF COLORADO AND GENERAL AND CHILD PSYCHIATRY AT THE UNIVERSITY OF PITTSBURGH, FOLLOWED BY POSTDOCTORAL FELLOWSHIP IN PSYCHIATRIC EPIDEMIOLOGY. HE FOCUSED HIS WORK ON IDENTIFYING RISK FACTORS FOR ADOLESCENT SUICIDE AND SUICIDAL BEHAVIOR AND TRANSLATION OF THOSE FINDINGS INTO AN ACTIONABLE INTERVENTION. HE IS A MEMBER OF THE NATIONAL ACADEMY OF SCIENCES AND HAS BEEN RECOGNIZED BY MANY ORGANIZATIONS FOR HIS RESEARCH. YOU HAVE AN ALL-STAR LINE UP THIS MORNING. IT WILL END IN A PANEL WHICH WILL BE EXPERTLY MODERATED BY DR. STEVEN GILMAN, THE ACTING CHIEF OF THE HEALTH BEHAVIOR BRANCH IN THE NICHD DIVISION. AND WITH DR. ARGYRIS STRINGARIS. I WANT TO GIVE A SPECIAL THANKS TO KALINE AND KEN TOBIN AND THE OTHERS FOR COORDINATING THIS EFFORT, AND WE HOPE YOU ENJOY THIS MORNING. [ APPLAUSE ] >> GOOD MORNING, EVERYONE. THANK YOU FOR BEING HERE. JUST A FEW HOUSEKEEPING ISSUES. IF YOU DO NEED CEUs REMEMBER TO SIGN IN AND YOUR EVALUATIONS ARE IN THE BACK OF YOUR PACKETS. THERE ARE RESTROOMS TO YOUR LEFT AS WELL AS A CAFETERIA OUT THROUGH THE DOUBLE DOORS. THERE IS TWO FIRE EXITS IF THERE IS AN EMERGENCY. SO WITHOUT ANY FURTHER DELAY, I WILL HAVE DR. DAVID BRENT COME UP AND SPEAK. [ APPLAUSE ] >> THANK YOU FOR INVITING ME AND THANK YOU FOR ORGANIZING THIS. AND IT'S A PLEASURE TO BE HERE. THE TITLE OF THIS TALK IS, WHAT DO I DO NOW? THIS IS BECAUSE IT REMINDS ME A LITTLE BIT OF THE JOKE THAT SOMEBODY ONCE ASKED YOGI BERRA WHAT TIME IT WAS. HE SAID, DO YOU MEAN NOW? AND IF YOU LOOK AT THE CHECK LIST THAT PEOPLE GIVE YOU FOR ASSESSING SUICIDAL RISK, THE CLINICIAN REALLY DOESN'T CARE WHETHER SOMEBODY IS AT RISK FIVE YEARS FROM NOW. WHAT THEY WANT TO KNOW IS, WHAT ARE THEY SUPPOSED TO DO NOW? SO THAT'S WHAT WE'RE GOING TO TRY AND FOCUS ON. HERE ARE MY DISCLOSURES. SO WHAT WE ARE GOING TO TALK ABOUT IS HOW TO ASSESS FOR IMMINENT SUICIDAL RISK, AND HOW TO DEVELOP A SAFETY PLAN ON THE BASIS OF THAT ASSESSMENT. WE'LL TALK A LITTLE BIT ABOUT EVIDENCE-BASED ASSESSMENTS AND INTERVENTIONS AND ABOUT AN INTERVENTION THAT BETSY KENNARD AT THE UNIVERSITY OF TEXAS SOUTHWEST AND I, DEVELOPED CALLED, ASAP, AS SAFE AS POSSIBLE. AND SOME GLIMPSE INTO THE FUTURE ABOUT DIRECTIONS THAT MAY BE PROMISING. SO, AS MARYLAND SAID, THE SUICIDE RATE IN ADOLESCENCE HAS BEEN GOING UP. IT ACTUALLY BEGAN INCREASING IN THE 60s AND IT PIQUED IN THE EARLY 1990S. AND IT THEN BEGAN TO DECLINE. AND I REMEMBER FEELING REALLY GRATIFIED THAT PERHAPS SOME OF THE WORK THAT WE HAD DONE MIGHT BE CONTRIBUTING TO THAT. BUT SINCE THE EARLY TWO THOUSANDS, THE RATE HAS BEEN GOING UP AGAIN. I REALLY DON'T WANT TO RETIRE UNTIL I SEE IT GOING DOWN AGAIN. ANYWAY, IT'S BEEN A VERY CONCERNING TREND. AS MARYLAND POINTED OUT, PARTICULARLY IN YOUNGER ADOLESCENCE, IN GIRLS, THE RATE IS -- I MEAN IT'S ABSOLUTELY LOW RATE BUT IN TERMS OF THE AMOUNT OF INCREASE, IT IS STAGGERING. WE DON'T REALLY KNOW WHY. LET'S JUST TALK ABOUT SOME DEFINITIONS. THOUGHTS OF DEATH REFER TO AS PASSIVE SUICIDAL IDEATION. YOU MIGHT THINK ABOUT WISHING TO BE DEAD BUT NOT HAVE ANY PLANS. YOU MIGHT THINK ABOUT WANTING TO KILL YOURSELF AND NOT HAVE A PLAN, OR INTENT. AND THEN A MORE SEVERE INDICATION OF SUICIDAL RISK WOULD BE HAVING EITHER PLAN OR INTENT TO KILL YOURSELF. I DON'T LIKE THESE TWO TERMS BUT THEY ARE THE ONES WE ARE STUCK WITH. ONE IS CALLED AN ABORTED SUICIDE. THAT'S WHERE THE PERSON STOPPED THEMSELVES. AND AN INTERRUPTED SUICIDE WOULD BE IF THERE HADN'T BEEN SOMEBODY ON THE SCENE, THEY WOULD HAVE MADE A SUICIDE ATTEMPT. AND A SUICIDE ATTEMPT WE DEFINE AS INTENTIONAL SELF INJURIOUS BEHAVIOR WITH AT LEAST, INFERRED INTENT TO DIE. AND WE DON'T USE THE TERM SUICIDE COMPLETION SO MUCH ANYMORE. BUT SUICIDE IS AN ATTEMPT THAT RESULTS IN FATALLY. AND THE TERM, GESTURE, I REALLY DISLIKE BECAUSE IT IMPLIES THAT BECAUSE SOMEBODY IS ENGAGED IN SUICIDAL BEHAVIOR, ISN'T THAT LETHAL? THAT YOU KNOW THE INTENT? YOU CAN'T ALWAYS INFER THE INTENT OF THE INDIVIDUAL FROM THE LETHALITY OF THE ATTEMPT. NOW NON-SUICIDAL SELF INJURY IS SOME KIND OF STEREOTYPICAL REPETITIVE BEHAVIOR OFTEN SELF-CUTTING. AND THE MOTIVATION IS DIFFERENT THAN TO KILL ONES SELF. IT IS EITHER TO RELIEF NEGATIVE AFFECT OR TO PUNISH ONE'S SELF. SOME OTHER MOTIVATIONS BUT THOSE ARE THE MOST COMMON ONES. TO THE EXTENT WE UNDERSTAND THE NEUROBIOLOGY, IT SEEMS TO DIVERGE A BIT FROM WHAT WE KNOW ABOUT THE NEUROBIOLOGY OF SUICIDAL BEHAVIOR. IN SO FAR AS THERE IS EVIDENCE THAT INVOLVES THE OPIOID RATHER THAN THE SEROTONERGIC SYSTEM. IT OFTEN COOCCURS WITH SUICIDAL BEHAVIOR. I PERSONALLY DON'T BELIEVE THAT THE THEORY THAT ENGAGING IN SELF INJURY REDUCES PEOPLE'S FEAR OF DEATH. BUT IT'S A VERY HARD THEORY TO DISPROVE. I WOULD JUST SAY THAT A LOT OF THE SAME FACTORS THAT LEAD SOMEBODY TO SELF INJURE, ALSO PREDISPOSE TO SUICIDAL BEHAVIOR. I THINK IT'S A SHARED DIE ATH SIS. SO NOT SURPRISING THAT A LOT OF KIDS WHO SELF INJURE THEN GO ON TO ATTEMPT SUICIDE. THE ACTION IS IN ADOLESCENCE WHEN THE PIQUE INCIDENCE OF SUICIDAL BEHAVIOR IS. IT PIQUES AROUND 15 OR 16. AND THIS COMES FROM A STUDY OF MATT KNOCKS FROM 2013. AGAIN, YOU CAN SEE THAT THE RATE OF SUICIDAL BEHAVIOR ANDIDATION GOES UP PARTICULARLY WITH PUBERTY, AND IT IS WHEN THE RATES FOR WOMEN GO UP MUCH FASTER THAN FOR MEN. YOU'LL SEE A LOT OF DIFFERENT STATISTICS ABOUT THE PREVALENCE OF THESE CONDITIONS. IF YOU LOOK AT THE YOUTH BEHAVIOR RISK SURVEY, THE RATES ARE MUCH, MUCH HIGHER. AND THAT IS BECAUSE THOSE ARE SELF-REPORT. WHEN PEOPLE INTERVIEW PEOPLE THEY FIND MUCH LOWER RATES. AND THERE ARE TWO REASONS FOR THAT. ONE IS THAT PEOPLE OFTEN WON'T DISCLOSE IN AN INTERVIEW. AND THE OTHER IS THAT IN A SELF-REPORT, PEOPLE DON'T ALWAYS UNDERSTAND THE QUESTION. SO PROBABLY THE SELF-REPORT QUESTIONS ARE AN OVERESTIMATE AND THE INTRODUCE ARE AN UNDERESTIMATE. ACCORDING TO THE INTERVIEW, ANYWAY, ABOUT 12% HAD SUICIDALIDATION AT SOME POINT IN THEIR LIFE. IF YOU LOOK AT THE YOUTH RISK BEHAVIOR SURVEYS, IT'S MORE IN THE LOW 20s. THE RATE OF SUICIDE ATTEMPTS IS ABOUT 6% IN GIRLS AND 2% IN BOYS. MUCH HIGHER IN THE YOUTH RISK BEHAVIOR SURVEY. THE RATE OF REOCCURRENCE IS ABOUT 30% IN THE YEAR AND THE RISK FOR SUICIDE IS ABOUT 1%. AND ABOUT 60-80% OF THESE KIDS HAVE A MOOD DISORDER ALONG WITH OTHER PSYCHOPATHOLOGY.& AND THIS GIVES YOU AN IDEA ABOUT WHAT HAPPENS WHEN SOMEBODY HASIDATION, WHAT THE LIKELIHOOD OF THEM GOING ON TO MAKE A SUICIDE ATTEMPT IS. THIS IS RETROSPECTIVE BUT THE PROSPECTIVE DATA ARE CONSISTENT. AND SO YOU CAN SEE MOST OF THE ACTION IS WITHIN THE FIRST YEAR. IN FACT, IT'S WITHIN THE FIRST FEW MONTHS AFTER PEOPLE PRESENT WITH IDEATION AND THE HIGHEST RISK FOR PEOPLE MAKING AN ATTEMPT IS FOR PEOPLE WHO HAVE IDEATION WITH A PLAN. AND JUST TO HIGHLIGHT HOW SERIOUS THIS IS, THIS IS A STUDY BY FINKELSTEIN FROM THE TORONTO SICK KIDS HOSPITAL. IT WAS A MASSIVE STUDY OF A FOLLOW-UP OF KIDS WHO OVERDOSED. AND THEY FOUND AN EXTRAORDINARILY HIGH INCREASED RISK OF SUICIDE AND THEY ALSO FIND AN INCREASED RISK OF DEATH FROM OTHER CAUSES AS WELL. AND THIS GIVES YOU AN IDEA OF THE HAZARD SO THAT THE HIGHEST RISK IS IN THE FIRST YEAR, BUT THEY CONTINUE TO BE AT ELEVATED RISK DURING THE ENTIRE PERIOD OF FOLLOW-UP. SO THERE ARE FIVE KEY DOMAINS WE WILL TALK ABOUT. SUICIDAL IDEATION AND BEHAVIOR, PSYCHIATRIC DISORDER AND PSYCHOLOGICAL TRAITS, CONTEXTURAL FACTORS AND THE AVAILABILITY OF LETHAL AGENTS. AND WITHIN SUICIDALITY, WE WILL TALK ABOUT FOUR AREAS, ASSESSING INTENT AND THE SEVERITY OF CURRENT IDEATION, REASONS FOR LIVING, LETHALITY, PRECYPITANT AND MOTIVATION. AND TO TELL YOU THE TRUTH, IF YOU KNOW THESE THINGS, YOU'RE PROBABLY 60-80% OF THE WAY THERE THERE. THE WAY I HAVE BEEN TAUGHT TO ASSESS SUICIDAL IDEATION IS TO BEGIN WITH NON-SPECIFIC QUESTIONS AND THEN PROGRESS. AND ONE OF THE -- SOME OF THE QUESTIONS THAT AREN'T NECESSARILY IN THE STRUCTURED INTERVIEWS THAT PEOPLE USE WOULD BE, ASKING SOMEBODY HOW LIKELY THERE A THINK THAT THEY ARE GOING TO CARRY OUT AN ACT. AND ALSO WHAT IS KEEPING THEM FROM ACTING ON IT? BECAUSE DEPENDING ON WHAT THAT IS, YOU MAY BE MORE OR LESS WORRIED ABOUT THEM, IN OTHER WORDS, IF THEY ARE CONCERNED ABOUT - IF THEY ARE SAYING THE ONLY THING THAT IS KEEPING THEM FROM KILLING THEMSELVES IS THE RELATIONSHIP WITH A GIRLFRIEND AND THEIR RELATIONSHIP IS VERY TENUOUS, THAT IS A LOT MORE WORRISOME THAN IF THEY SAID, I DON'T WANT TO HURT MY FAMILY, I LOVE THEM AND I THINK IT WOULD BE TOO HURTFUL TO THEM. AND YOU ALSO WANT TO KNOW WHAT MIGHT HAPPEN TO INCREASE SOMEBODY'S LIKELIHOOD TO ATTEMPT SUICIDE. NOW WITHIN THE IDEATION, THERE ARE A NUMBER OF THINGS THAT HAVE BEEN SHOWN TO PREDICT AN ATTEMPT. ONE IS THE FREQUENCY, ONE IS THE INTENSITY, WHICH WE, BY THIS WE MEAN THE -- WHAT EXTENT ARE THEY REALLY PREOCCUPIED WITH SUICIDAL IDEATION AND CAN'T DISTRACT THEMSELVES OR DIRECT THEIR ATTENTION SOMEWHERE ELSE? SEVERITY IS WHAT WE HAVE BEEN TALKING ABOUT, HOW ACTIVE, HOW MUCH INTENT, WHETHER THEY HAVE A SPECIFIC PLAN. AND YOU ALSO WANT TO KNOW WHAT IS THE WORST THAT THEY HAVE EVER -- WHAT IS THE GREATEST SEVERITY OF SUITS IDEATION THEY EVER HAD, BECAUSE -- SUITS -- BECAUSE THAT TURNS OUT TO BE A POWERFUL PREDICTOR FOR SUICIDAL BEHAVIOR. WHAT YOU'RE TRYING TO ASSESS IS THE BALANCE BETWEEN THE WISH TO LIVE AND THE WISH TO DIE. AND THEY COINCIDE WITH ONE ANOTHER. ABOUT 60% TOLD SOMEBODY THEY WERE THINKING ABOUT KILLING THEMSELVES. THIS STUDY WAS DONE IN THE MID 80s WHEN THERE WAS A CODE OF SILENCE AND KIDS KNEW THAT YOU WOULDN'T BREAK A CONFIDENCE NO MATTER WHAT. BUT THE FACT IS, WHEN I LEARNED THAT I REALIZED, THESE KIDS WANTED TO LIVE, I MEAN AT LEAST SOME WAYS. THEY WOULDN'T HAVE TOLD SOMEBODY OTHERWISE. THAT YOU HAVE TO REALIZE THAT BOTH OF THESE ARE COEXISTING AND YOU WANT TO PUSH THINGS MORE IN THE DIRECTION OF WANTING TO LIVE. YOU WANT TO KNOW WHAT ARE THE THINGS THAT ARE KEEPING PEOPLE FROM ACTING ON THOSE SUICIDAL THOUGHTS BECAUSE YOU WANT TO AUGMENT THEM IF YOU CAN. AND IF SOMEBODY MADE A SUITS ATTEMPT, YOU WANT TO KNOW TO WHAT EXTENT DO THEY FEEL REGRET FOR SURVIVING OR ARE THEY FEEL FEELING THAT THEY REGRET ACTUALLY HAVING THE ACT. WE KNOW ASKING ABOUT SUICIDE DOESN'T INCREASE THE RISK. MADELINE GULD RANDOMIZED KIDS AND SEASED RISK FACTORS FOR SUICIDAL BEHAVIOR AND THEN SOME OF THEM THEY ASKED ABOUT IDEATION AND SOME OF THEM THEY DIDN'T AND IT SHOWED IN FOLLOW-UP, THERE WAS NO DIFFERENCE IN THE RISK OF SUICIDE ATTEMPT. NOW SUICIDAL INTENT IS THE DEGREE TO WHICH SOMEBODY WANTS TO DIE. WHAT YOU WANT TO DO IS GO BY OBSERVABLE BEHAVIOR AND NOT ONLY SELF REPORT. YOU WANT TO KNOW WHAT THEY THOUGHT WAS GOING TO HAPPEN. SO A KID WHO THINKS SHE GOING TO DROWN HIMSELF IN THE BATHTUB SUICIDAL INTENT, EVEN THOUGH IT IS REALLY HARD TO DO THAT. YOU WANT TO KNOW WHAT KIND OF PREPATORY BEHAVIOR, WHETHER THEY TIMED IT SO SOMEBODY WOULDN'T DISCOVER THEM, WHETHER THEY COMMUNICATED INTENT BECAUSE PEOPLE WHO COMMUNICATE INTENT ARE AT VERY HIGH RISK. WE USED TO THINK THAT PEOPLE WHO TALK ABOUT SUICIDE AREN'T GOING TO DO IT, BUT WHAT THIS INDICATES IS A CERTAIN STABILITY AND PERSISTENCE OF IDEATION AND THE FACT THAT THEY ARE TALKING ABOUT IT MEANS THAT THEY ARE MORE PREOCCUPIED. TRYING TO UNDERSTAND THE MOTIVATION IS GOING TO SHAPE WHAT DIRECTION YOU GO IN TERMS OF YOUR TREATMENT PLAN. THE MOST COMMON REASONS THAT KIDS GIVE FOR SUICIDE ATTEMPTS ARE WELL EITHER BECAUSE THEY WANTED TO DIE, OR THEY WANTED TO ESCAPE MENTAL PAIN. THERE ARE OTHER REASONS SOMETIMES PEOPLE WANT TO COMMUNICATE HOSTILITY, OR WANT TO GET PEOPLE TO PAY ATTENTION TO THEM. AGAIN, THE REASONS WHY THEY ARE ENGAGING IN THE BEHAVIOR TELL YOU YOU HAVE TO FIGURE OUT A WAY TO HELP THIS KID GET THEIR NEEDS MET IN A WAY THAT ISN'T SO LIFE-THREATENING. SO IF THEY ARE HAVING DIFFICULTY WITH MENTAL PAIN, THEN YOU WANT TO TEACH THEM TO STRESS TOLERANCE IN WAYS TO REGULATE THAT PAIN. IF THEY ARE TRYING TO COMMUNICATE HOSTILITY, MAYBE YOU HAVE TO TEACH THEM HOW TO COMMUNICATE THAT IN A WAY THAT DOESN'T PUT THEM AT DEATH'S DOOR. YOU WANT TO KNOW WHAT PRECIPITATED THE ATTEMPT. YOU CAN'T ALWAYS FIGURE THIS OUT. BUT BECAUSE YOU'RE TRYING TO ASSESS WHAT IS GOING ON IN THE KIDS ENVIRONMENT THAT MAY LEAD TO THIS, AND PARTICULARFULLY IT'S A PRECIPITANT THAT IS GOING TO REOCCUR, THEN YOU HAVE TO FIGURE OUT A WAY TO DEAL WITH IT. LIKE IF A KID WANTS TO KILL HIMSELF BECAUSE HE IS BEING BULLIED, AND THAT IS GOING ON AND ON IN THE SCHOOL, THEN THAT IS A DIFFERENT SITUATION THAN A KID WHO MAYBE FAILED A TEST. BUT IT'S VERY -- BECAUSE THEN YOU HAVE TO EITHER MANIPULATE THE ENVIRONMENT OR GIVE THE KID A WAY TO COPE WITH THAT STRESS STRESSER. AND SOME OF THE MOST COMMON PRECIPITANTS IN YOUNGER KIDS IS CONFLICT WITH PARENTS. IN OLDER ADOLESCENTS, IT'S CONFLICT WITH PIERCE. DISAPPOINTMENT, SCHOOL PROBLEMS, LEGAL AND DISCIPLINARY ISSUES. KIDS BEING ABUSED OR HAVE BEEN ASSAULTED. BEING BULLIED IS QUITE COMMON. AND KIDS CONCERNS ABOUT THEIR SEXUAL ORIENTATION. SO THE NEXT DOMAIN IS PSYCHOPATHOLOGY. AND THE ISSUE IS THAT PSYCHOPATHOLOGY IS A NECESSARY BUT NOT SUFFICIENT EXPLANATORY FOR SUICIDAL BEHAVIOR. BECAUSE THE MAJORITY OF PEOPLE WITH PSYCHOPATHOLOGY DON'T ATTEMPT SUICIDE AND THEY CERTAINLY DON'T KILL THEMSELVES. SO, WHATEVER -- THE MANTRA USED TO BE, IF YOU TREAT PSYCHIATRIC DISORDER, THEN YOU CAN REDUCE SUICIDE. THAT'S TRUE TO AN EXTENT BUT BECAUSE OF THE FACT THAT MOST PEOPLE WHO ARE -- WHO HAVE PSYCHOPATHOLOGY DON'T EVEN ENGAGE IN SUICIDAL BEHAVIOR, THERE HAS TO BE OTHER VULNERABILITIES THAT YOU NEED TO ADDRESS. AND I WOULD SAY ALMOST ANY DISORDER INCREASES THE RISK FOR SUICIDE. PROBABLY EATING DISORDERS HAS THE HIGHEST RISK. AND PROBABLY THAT AND BIPOLAR DISORDER. BUT THE FACT IS THAT WHAT YOU WANT TO LOOK FOR IS SEVERITY AND CO-MORBIDITY. THE MORE DISORDERS YOU HAVE, THE HIGHER THE RISK. SUICIDE AND SUICIDAL BEHAVIOR IS ELEVATED IN CHRONIC MEDICAL ILLNESSES. PARTICULARLY THOSE THAT INVOLVE THE CNS, SUCH AS MIGRAINE OR CONCUSSION OR EPILEPSY. AND THOSE RELATED TO INFLAMMATION LIKE ASTHMA OR INFLAMMATORY BOWEL DISEASE. AND SOME OF THE TREATMENTS SOMETIMES CAN ALSO PREDISPOSE TO SUICIDAL BEHAVIOR. NOW IN YOUNGER KIDS, SAY UNDER THE AGE OF 15, WHEN WE COMPARED THEM TO OLDER ADD LES WON'T KILLED THEMSELVES, THEY SHOW LOWER INTENT AND PLANNING. THERE IS A SUBGROUP GROUP IN OUR STUDIES THAT PROBABLY DIDN'T INTEND TO KILL THEMSELVES AT ALL BECAUSE WE FOUND THAT IN KIDS UNDER THE AGE OF 15, ONLY 60% OF THEM HAD A PSYCHIATRIC DISORDER. AT LEAST THAT WE WERE ABLE TO RECONSTRUCT. THE BIGGEST RISK FACTOR FOR THOSE KIDS WHO DIDN'T SEEM TO HAVE A DISORDER WAS HAVING A LOADED GUN IN THE HOUSE. SO IT'S POSSIBLE THAT IT WAS AN IMPULSIVE ACT IN A KID WHO IN A FIT OF TEMPER OR WHATEVER WAS GOING ON, THAT MAYBE REALLY DIDN'T HAVE A STABLE SUICIDAL IDEATION THAT HAD BEEN PLANNING THIS FOR A LONG TIME. AND SO YOU SEE LOWER RATES OF PSYCHIATRIC DISORDER. THE MOOD DISORDER IS LESS INVOLVED IN BEHAVIORAL DISORDERS BUT YOU SEE VERY LITTLE SUBSTANCE ABUSE IN YOUNGER SUICIDAL KIDS. AS ONE MIGHT EXPECT, THE PARENT CHILD RELATIONSHIP AND PARTICULARLY ABUSE ARE MORE SIGNIFICANT CONTRIBUTOR IN YOUNGER KIDS. AND THE AVAILABILITY OF AGENTS IS MORE IMPORTANT THAN PSYCHOPATHOLOGY IN YOUNGER KIDS. SO THAT THE IDEA THAT PEOPLE ARE EMPHASIZING SCREENING OF YOUNG 11-YEAR-OLDS AS A WAY OF PREVENTING SUICIDE, IT'S PROBABLY NOT THE BEST -- IT WOULD PROBABLY BE BETTER OFF SAFETY PROOFING PEOPLE'S HOMES TO PREVENT SUICIDAL IN YOUNGER KIDS. AND THEN THERE IS CERTAIN PSYCHOLOGICAL TRAITS THAT CONTRIBUTE TO RISK FOR SUICIDAL BEHAVIOR. HOPELESSNESS, POSEIMISM ABOUT THE FUTURE. THIS PREDICTS DROPOUT FROM TREATMENT. POOR TREATMENT RESPONSE AND PREDICTS SUICIDE ATTEMPTS. IMPULSIVITY AND AGGRESSION ARE STRONG PREDICTORS OF EARLY-ONSET SUICIDAL BEHAVIOR AND SOME OF OUR STUDIES HAVE SHOWN THIS IS ONE OF THE FACTORS THAT MEDIATES THESE FAMILIAL TRANSMISSION OF SUICIDAL BEHAVIOR. MARSHA HAS PIONEERED THE ASSESSMENT AND TREATMENT OF SELF-DESTRUCTIVE BEHAVIOR, AND THE DIFFICULTY WITH STRESS TOLERANCE AND EMOTION REGULATION ARE REALLY CRITICAL TO ASSESS IN KIDS WHO ARE SELF-HARMING. AND SOMETHING THAT I'M GOING TO REFERENCE LATER IS THERE SEEMS TO BE WHAT IS CALLED OVER-GENERAL AUTO BY GRAPHIC MEMORY. WHEN YOU ASK THEM TO RECALL SOMETHING, PARTICULARLY SOMETHING THAT IS POSITIVE, THEY CAN'T RECALL IT WITH THE SAME DEGREE OF DETAIL THAT SOMEBODY WHO IS HEALTHY CAN. AND PEOPLE HAVE HYPOTHESIZED THAT THEREFORE IF SOMEBODY LEARNS CERTAIN SKILLS OR THEY WANT TO COUNTER ACT THEIR NEGATIVE AFFECT WITH SOMETHING PLEASANT, THEY ARE LESS ABLE TO DO THAT. AND I WOULD SAY THIS IS TRUE MORE IN PEOPLE OVER THE AGE OF 40 BUT A CERTAIN DEGREE OF INFLEXIBILITY SEEMS TO BE A PSYCHOLOGICAL TRAIT ASSOCIATED WITH SUICIDE. ESPECIALLY IN KIDS, THERE ARE A LOT OF CONTEXTURAL ISSUES. FAMILY HISTORY OF PSYCHIATRIC DISORDER AND BEHAVIOR. AND WE KNOW FOR EXAMPLE THAT IF THE MOM CARE TAKING PARENT REALLY IS DEPRESSED, THAT THE TREATMENT OF DEPRESSION IS MUCH LESS EFFECTIVE. ABUSE AND NEGLECT, DISCORD, COMPLICATED GRIEF. I'M NOT GOING TO SPEND A LOT OF TIME ON THAT BUT IN KIDS WHO ARE BEREAVED, THE IDEA OF REALLY NOT BEING ABLE TO MOVE ON AND BEING PREOCCUPIED WITH THE LOSS, IT SEEMS TO BE A DIFFERENT PHENOMENA THAT LIKE IF YOU TREAT THE DEPRESSION AND ANXIETY THAT OFTEN COOCCURS WITH IT, THESE KIDS STILL DON'T DO THAT WELL AND YOU HAVE TO ADDRESS THESE ISSUES USING SOME SPECIFIC PSYCHOTHERAPEUTIC TECHNIQUES. KDS WHO ARE DISCONNECTED. MADELINE GOULD IN HER PSYCHOLOGICAL STUDIA SHE DID WITH DAVID SHERIFF, IDENTIFIED A LOT OF -- DAVID SCHAFER -- IDENTIFIED OLDER ADOLESCENCE THAT WEREN'T IN SCHOOL, WEREN'T WORKING, WEREN'T LIVING WITH THEIR FAMILIES. THEY WERE JUST DRIFTING. KIDS WHO ARE BEING BULLIED OR ARE BULLIERS, OR BOTH, ARE AT VERY HIGH RISK. AND KIDS WHO HAVE SAME-SEX ATTRACTION OR TRANSGENDER ARE INCREASED RISK. ALTHOUGH IT IS INTERESTING, THERE WAS RECENTLY A STUDY THAT SHOWED THAT IF YOU LOOKED AT KIDS, TRANSGENDERED KIDS WHOSE PARENTS SUPPORTED THEIR TRANSITION, THEY DIDN'T SEEM TO SHOW MUCH IN THE WAY OF MENTAL HEALTH PROBLEMS COMPARED TO CONTROLS. IT WAS A SMALL STUDY AND I THINK IT WAS A CONVENIENT SAMPLE. BUT I THINK THERE ARE A NUMBER OF STUDIES THAT SHOW THAT CONTEXTURAL ISSUES MATTER. IT WANT ISN'T NECESSARILY SAME-SEX ATTRACTION, PER SE. IT'S THE BULLYING THAT GOES ALONG WITH IT OR THE FAMILY REJECTION THAT IS THE PROBLEM. AND CONVERSELY, THERE ARE A NUMBER OF PROTECTIVE FACTORS THAT HAVE BEEN SHOWN TO REDUCE THE SUICIDAL RISK EVEN IN THE FACE OF OTHER RISK FACTORS. AND THERE NOW ARE THREE STUDIES THAT WERE PREVENTION STUDIES NOT FOCUSED ON SUICIDE. THEY WERE FOCUSED ON AUGMENTING FAMILY RESILIENCE, IMPROVING PARENT/CHILD CONNECTION, HELPING THE PARENTS TO MORE APPROPRIATELY SUPERVISOR AND DISCIPLINE, AND YEARS LATER WHEN THEY FOLLOWED UP THESE KIDS, THEY SHOWED A LOWER RATE OF EITHER SUICIDAL IDEATION OR BEHAVIOR. IT'S A IMPORTANT THING TO THINK ABOUT, ALTHOUGH SOMETIMES IT ISN'T THE FIRST THING THAT YOU DEAL WITH. BUT AS IN THE CONSOLIDATION PHASE OF TREATMENT, WE TRY TO FOCUS ON THIS. AND IT'S IMPORTANT TO RECOGNIZE THERE ARE A LOT OF HEALTH RISK BEHAVIORS. IF YOU RECALL THAT STUDY OF FINKELSTEIN, THE KIDS WHO MADE OVERDOSES WERE MORE LIKELY TO DIE IN AN ACCIDENT. SO YOU WANT TO TAKE A BROADER VIEW OF ALL THE HEALTH RISK BEHAVIORS THAT ARE GOING ON WITH THESE KIDS. YOU DON'T WANT TO QUOTE/UNQUOTE, SAVE THEM FROM SUICIDE AND THEN HAVE THEM GET IN A CAR WITH A DRUNK DRIVER AND DIE FROM THAT BECAUSE THERE IS A TENDENCY TO TAKE THESE OTHER RISKS AS WELL. AND FINALLY, THERE IS THE DOMAIN OF THE AVAILABILITY OF LETHAL AGENTS. THERE ARE A TON OF STUDIES NOW LOOKING AT GUNS, LOOKING AT DOMESTIC GAS IN THE U.K., USING BLISTER PACKS FOR ACETAMINOPHEN WHICH THERE IT IS CALLED PARASEAT MEDICAL, WHICH MAKES IT MUCH HARDER TO GET ENOUGH PILLS TO KILL YOURSELF AND LOOKING AT THE AVAILABILITY OF SSRIs VERSUS TCAs. WITH SSRIs IT'S HARD TO KILL YOURSELF. TRICYCLICS, ONE PRESCRIPTION YOU CAN KILL YOURSELF. DEPENDING ON THE RATIO OF THE PRESCRIPTIONS, YOU CAN SEE A DIFFERENCE IN THE SUICIDE RATE EVEN THOUGH IN ADULTS THEIR EFFICACY EQUIVALENT. AND IN ASIA, PESTICIDES ARE THE MOST COMMON CAUSE OR METHOD OF SUICIDE. AND IF YOU LOOK AT STUDIES WHERE THEY HAVE RESTRICTED SALES OR GIVE PEOPLE LOCKBOXES TO MAKE THE PESTICIDES LESS AVAILABLE, THEN THE SUICIDE RATES IN THAT METHOD AND OVERALL WILL DECLINE. AND THIS IS A GROWING AREA OF RESEARCH. IT'S NOT SOMETHING I WOULD SAY I KNOW PARTICULARLY WELL, BUT I TRIED TO IMMERSE MYSELF IN IT RECENTLY. THERE HAVE BEEN A NUMBER OF COREULATIVE STUDIES THAT HAVE SHOWN THAT GREATER USE OF THE INTERNET IS ASSOCIATED WITH SUICIDAL IDEATION. AND THERE WAS ONE STUDY, THE HOKBY STUDY THAT WAS A LONGITUDINAL STUDY AND WAS ABLE TO DEMONSTRATE THAT THE QUESTION IS, IS IT ICEULATIVE SUICIDAL KIDS ARE ON THE INTERNET MORE? OR BEING ON THE INTERNET CAUSES THEM TO BE SUICIDAL? AND AT LEAST ACCORDING TO THAT ONE STUDY, IT LOOKS LIKE IT WAS THE LATTER. THAT IT WAS THE USE OF INTERNET THAT SEEMED TO BE RELATED TO INCREASE IN SUICIDAL IDEATION. AND THERE SEEMS TO BE A NUMBER OF MECHANISMS THAT PEOPLE HAVE ALLUSE DATED. ONE IS SOCIAL COMPARISON ON SOCIAL MEDIA COMPARING EVERYBODY ELSE LOOKS REALLY HAPPY. THERE IS A LOT OF CYBER BULLYING AND THE MORE THAT KIDS ARE ON THE INTERNET, THE MORE LIKELY THEY ARE TO BE CYBER BULLIED. KIDS USE SOCIAL MEDIA CLOSE TO THE TIME WHERE THEY ARE SUPPOSED TO BE GOING TO BED AND THE IT'S ASSOCIATED WITH DECREASED SLEEP AND WE KNOW THAT THAT, INSOMNIA IS A SIGNIFICANT RISK FACTOR FOR SUICIDE. AND THERE IS ALSO EVIDENCE THAT PEOPLE WHO ARE SUICIDAL ARE MORE LIKELY TO ENGAGE IN SEARCHES FOR RELATED TO SUICIDE. UNFORTUNATELY, TWO-THIRDS OF THOSE SEARCHES ARE RELATED TO METHODS FOR KILLING THEMSELVES. AND 1/3 ARE LOOKING FOR HELP. AND I THINK NOW FACEBOOK HAS DONE SOMETHING TO TRY TO COUNTER THAT. I'M NOT EXACTLY SURE WHAT IT IS. BUT YOU CAN THINK ABOUT WHAT ARE -- THAT YOU COULD HAVE AN AUTOMATIC RESPONSE IF SOMEBODY DOES THAT, GIVE THEM THE NUMBER OF A CRISIS TEXT LINE OR SOMETHING LIKE THAT. AND VERY INTERESTINGLY, THE FACTOR THAT MODERATED THE IMPACT OF SOCIAL MEDIA AND THE INTERNET ON KIDS SUICIDALITY WAS FAMILY MONITORING. PARENTS WHO KNEW WHAT THEIR KIDS WERE DOING, PUT FILTERS ON. THOSE KIDS, THE USE OF THE INTERNET WAS NOT AS TOXIC. AND FINALLY, WE USED TO TALK ABOUT CONTAGION IN TERMS OF TIME/SPACE CLUSTERS. BUT NOW PEOPLE CAN BE EXPOSED WITHOUT NECESSARILY BEING CLOSE IN SPACE. AND THERE IS EVIDENCE FROM TWITTER THAT PEOPLE WHO ARE SUICIDAL ARE IN MUCH TITER SOCIAL NETWORKS THAN PEOPLE WHO AREN'T SUICIDAL. AND SUBSEQUENTLY, THE MULTIPLICATIVE EFFECT OF EXPOSURE -- LIKE THE PRO PORTION OF INPUT FROM OTHER SUICIDAL PEOPLE IS HIGHER. SO LET'S TALK ABOUT ASSESSMENT OF IMMINENT RISK NOW THAT WE KNOW ALL THIS STUFF. SO THIS IS MY ACRONYM. IAMILL. FIRST OF ALL, YOU WANT TO LOOK AT IDEATION WHETHER THERE IS A PLAN, INTENT, FREQUENCY AND INTENSITY. THAT'S THE SINGLE MOST IMPORTANT ISSUE. YOU WANT TO LOOK AT AGITATION, WHICH BY THAT IT COULD BE ANXIETY, EXTRA PARAMEATAL SYMPTOMS OR RELATED TO INSOMNIA. YOU WANT TO LOOK AT MENTAL PAIN. SO THAT IT'S NOT -- DEPRESSION NEVER KILLED ANYBODY. IT'S PEOPLE SAYING, I COULDN'T STAND THE PAIN OF DEPRESSION THAT KILLED THEM. AND SO, YOU WANT TO ASSESS LIKE HOW MUCH DO YOU HURT? INSTABILITY. IN OTHER WORDS YOU WANT TO BE ABLE TO TELL -- LIKE SOMEBODY MIGHT LOOK OKAY IN THE ED RIGHT THEN BUT BASED ON WHAT IS GOING TO WITH THEM, YOU MIGHT -- LIKE FOR EXAMPLE SOMEBODY IN A MIXED STATE OR RAPIDLY CYCLING, YOU CAN'T REALLY PREDICT WHAT IS GOING TO HAPPEN. AND THERE IS A HIGH LIKELIHOOD THAT IN THE NEAR FUTURE, THEY ARE NOT GOING TO BE ABLE TO KEEP THEMSELVES SAFE BECAUSE THEY ARE GOING TO BE INTOXICATED OR THEY WILL BE DEPRESSED OR WHATEVER. AND SO THOSE ARE THINGS THAT YOU WANT TO TAKE A LOOK AT. LOSS OF A RELATIONSHIP OR OF HEALTH OR FUNCTION. THIS REALLY CUTS ACROSS ALL AGE GROUPS. BUT CAN BE A POWERFUL FACTOR. AND FINALLY THE AVAILABILITY OF A LETHAL AGENT. AND I'M NOT A BIG ONE FOR THEORY BUT I THINK THAT YOU THINK ABOUT THE IMMINENT RISK IS REALLY LOOKING AT THE BALANCE BETWEEN DISTRESS AND RESTRAINT. AND THE KIND OF THINGS THAT ARE GOING TO INCREASE DISTRESS, MENTAL PAIN, AGITATION, PEOPLE WITH IMPULSIVE AGGRESSION, PEOPLE WHO ARE INTOXICATED. SOME OF THESE THINGS SHOW UP ON BOTH SIDES. AND THEN YOU WANT TO LOOK AT WHAT ARE THE THINGS THAT ARE GOING TO INCREASE RESTRAINT? SO, SO BRIGHTY, SAFE STORAGE OF LETHAL AGENTS, KIDS WHO HAVE A LOT OF REASONS FOR LIVING, WHO ARE ABLE TO ENGAGE IN DISTRESS TOLERANCE WHO HAVE SOCIAL SUPPORT. AND THIS IS BASICALLY YOUR ASSESSMENT OF IMMINENT RISK. AND HOW YOU -- AND YOU BASICALLY WANT TO PUSH THINGS IN THE DIRECTION WHERE YOU ARE RELIEVING DISTRESS AND YOU ARE INCREASING RESTRAINT. AND THIS WAS A COOL STUDY LOOKING AT WHEN IN YOUR LIFE DID DIFFERENT THINGS START? SO YOU SEE THAT SOMEBODY MAY BE BEGAN HAVING SUICIDAL IDEATION LIKE FIVE YEARS AGO. THEN TWO WEEKS BEFORE THE ATTEMPT, THEY BEGAN TO THINK ABOUT IT MORE SERIOUSLY. AND THEN SIX HOURS BEFORE THE ATTEMPT, THEY WERE MULLING. THE IDEA IS THAT WHAT HAPPENS IS IN THE LAST SIX HOURS MOST OF THE STEPS THAT YOU NEED TO TAKE TO MAKE A SUICIDE ATTEMPT IN YOUNG ADULTS AND PRESUMABLY IN ADOLESCENCE, TAKE PLACE SO THAT THIS IDEA THAT WE ARE GOING TO SCREEN FOR RISK WAY UP STREAM, WE ARE GOING -- IT IS IMPORTANT. BUT THE ISSUE IS THAT A LOT OF WHAT HAPPENS IS IN THE LAST FEW HOURS BEFORE SUICIDAL BEHAVIOR ENSUES. SO YOU WANT -- AS A CLINICIAN, YOU WANT TO BE DOING THINGS THAT ARE GOING TO PREVENT THOSE THINGS FROM PROGRESSING. SO WHAT ARE THE STUDIES FOR WHICH THERE ARE SOME EVIDENCE THAT WE CAN REDUCE EITHER SUICIDAL IDEATION OR BEHAVIOR? THERE IS DIALECTIC BEHAVIOR THERAPY AND THERE WAS A VERY NICE STUDY FROM NORWAY BY MELHUM WHO LOOKED AT PEOPLE WITH SELF-HARM ON THE OTHER SIDE OF THE ATLANTIC. PEOPLE CLASSIFY SELF-DESTRUCTIVE BEHAVIOR DIFFERENTLY. THEY GROUP NON-SUICIDAL SELF INJURY AND SUICIDE ATTEMPTS TOGETHER. SO YOU CAN'T REALLY DISAGGREGATE IT BUT IT IS LIKELY THAT IT WAS EFFECTIVE FOR BOTH. AND IT ALSO SHOWED A DECREASE IN SUICIDAL IDEATION. THERE IS A PAPER THAT IS NOW BEEN SUBMITTED AND IT HAS BEEN PRESENTED. IT WAS A STUDY LED BY ELIZABETH AND JOE LOOKING AT DBT FOR SELF-HARMING ADOLESCENCE AND THEY ALSO SHOWED A DECREASED INCIDENCE OF SUICIDE ATTEMPTS. THERE IS ATTACHMENT-BASED FAMILY THERAPY, A BRIEF THERAPY THAT INCREASES THE CONNECTION BETWEEN PARENT AND CHILD. THAT IS SHOWN DECREASE IN SUICIDAL IDEATION. THERE IS ONGOING -- I THINK IT'S BEEN FINISHED NOW BUT A CLINICAL TRIAL TO SEE IF IT HAS AN EFFECT ON SUICIDE ATTEMPTS. THERE IS A BRIEF INTERVENTION CALLED RAP. P THAT BASICALLY FOCUSES ON -- RAPP, FOCUSING ON PARENTS OF ADOLESCENCE WHO ARE SUICIDAL AND SELF HARMING AND TEACHES THEM BETTER PARENTING SKILLS. AND THERE IS A STUDY THAT USES SOMETHING CALLED MENTALLIZATION THAT WAS DEVELOPED BY PETER FONAGY. HOW TO EXPLAIN THAT? WHAT HE SAID IS MENTALLIZATION IS THE ABILITY TO REPRESENT ACTION IN TERMS OF THOUGHTS AND FEELINGS. SO BASICALLY IT'S TO TRY TO GET PEOPLE TO CONCEPTUALIZE WHAT THEY ARE GOING TO DO BEFORE THEY DO IT. AND TO KEEP FROM ACTING ON DISTRESSING IMPULSES. AT LEAST THAT IS THE WAY I UNDERSTAND IT. THERE ARE STUDIES OF COGNITIVE BEHAVIOR THERAPY AND JOAN HAD A SMALL STUDY WITH A FAMILY COGNITIVE BEHAVIOR THEY WERE THEY SEEMED TO PREVENT ATTEMPTS. SO WE ARE BEGINNING TO GET SOME TOOLS IN OUR TOOLBOX, ALTHOUGH EXCEPT FOR THE DBT, THERE HAS BEEN NO LARGE-SCALE STUDIES OR REPLICATION. WHAT ARE THE THINGS THAT ARE IN COMMON IN THESE DIFFERENT TREATMENTS? THE MOST IMPORTANT IS THAT THERE IS AN EXPLICIT FOCUS ON SUICIDAL RISK. YOU ASK THE KID EACH TIME YOU SEE THEM, TO WHAT EXTENT ARE YOU THINKING ABOUT KILLING YOURSELF? AND THAT YOU KEEP THAT FRONT AND CENTER. THEY EDUCATE THE PARENT AND FAMILY ABOUT WHAT THEY ARE GOING TO DO. THEY ADDRESS BARRIERS TO TREATMENT EXPLICITLY. THERE IS A FOCUS ON PARENT-CHILD INTERACTION. IT'S AN ADEQUATE DOSE. I KNOW JOAN SAID SHE THOUGHT SIX MONTHS OF DBT WASN'T ENOUGH FOR A LOT OF THESE FAMILIES. THERE IS A SAFETY PLAN AND WE'LL TALK ABOUT THAT. IT'S SKILLS FOCUSED. AND THAT IT FOCUSES ON TRANSDIAGNOSTIC RISK FACTORS. LIKE INSOMNIA, ALCOHOL AND DRUGS. LIKE TRAUMA AND SO ON. AND THOSE ARE THINGS THAT ARE GOING TO INCREASE YOUR RISK WHETHER YOU'RE SCHIZOPHRENIC, EATING DISORDER, ANXIOUS, WHATEVER. SO, IN TRYING TO FIGURE OUT WHAT IS GOING ON WITH A KID, WORN OF THE THINGS THAT IS COMMON TO A NUMBER OF THESE -- ONE OF THE THINGS -- YOU DO A CHAIN ANALYSIS WHICH IS ATTEMPT TO RECONSTRUCT WHAT IT IS THAT -- WHAT ARE THE THOUGHTS, FEELINGS, AND EVENTS THAT HAVE LED UP TO THE SUICIDE ATTEMPT? SO HERE IS ONE EXAMPLE. A KID SAYING THERAPIST IS SAYING, TELL ME WHAT LED UP TO YOUR ATTEMPT. AND THE KID SAYS, I WAS FEELING LOW SO I DRANK SOME OF MY DAD'S SCOTCH. AND THEN I CALLED MY GIRLFRIEND. AND THEN SHE HUNG UP ON ME. WHAT DID YOU THINK AND FEEL? I WAS BUMMED AND I THOUGHT, WHAT THE HELL, I MIGHT AS WELL END IT. DID YOU THINK OF ANYTHING ELSE? HE SAYS, NOT REALLY. SO THIS IS HOW A CHAIN ANALYSIS WOULD LOOK. THE PRECIPITANT -- HE STARTED OUT FEELING LOW. HE DRANK, WHICH THEN INCREASED HIS VULNERABILITY. HE CALLED THE GIRLFRIEND. SHE HUNG UP ON HIM AND THEN HE FELT WORSE. HE DIDN'T CONSIDER OTHER ALTERNATIVES AND AS WE LEARNED FROM TALKING WITH HIM FURTHER, HE FELT HOPELESS, HE WANTED TO ENGAGE IN THIS BEHAVIOR TO GET BACK AT HER AND HE COULDN'T STAND HOW HE WAS FEELING. SO, IN ORDER TO DEVELOP A SAFETY PLAN, YOU WANT TO IDENTIFY THE TRIGGERS, YOU WANT TO IDENTIFY THE EMOTIONS ASSOCIATED WITH THE TRIGGERS, AND YOU WANT TO FIGURE OUT WAYS TO COPE WITH THOSE SUICIDAL URGES. SO, YOU EITHER AVOID THE TRIGGERS OR YOU FIGURE OUT A WAY TO COPE WITH THEM. AND THEN THERE ARE OTHER THINGS THAT YOU CAN DO TO TRY AND COPE WITH SUICIDAL URGES. YOU CAN DISTRACT YOURSELF. YOU CAN TALK TO SOMEBODY. YOU CAN REVIEW YOUR REASONS FOR LIVING. AND IF YOU'RE REALLY FREAKED OUT, YOU CAN CALL YOUR THERAPIST OR CRISIS LINE. SO, IN THIS CASE, THE PRECIPITANTS, YOU MIGHT THINK LIKE DON'T CALL THE GIRLFRIEND AND DON'T DRINK. I KNOW EASIER SAID THAN DONE. BUT IN THE IDEAL WORLD THOSE ARE THINGS YOU WOULD WANT HIM TO DO. YOU FIND OUT THAT LISTENING TO MUSIC CAN BE HELPFUL FOR HIM OR EXERCISE OR MEDITATION. AVOIDING STRESSFUL DISCUSSIONS. AND THEN IDENTIFYING PEOPLE THAT HE CAN REACH OUT TO. AND I WANT TO EMPHASIZE THAT WHEN KIDS ARE -- WE HAVE THEM CALL OTHER KIDS, WE STRESS TO THEM THEY ARE NOT TO DISCUSS THEIR SUICIDAL THOUGHTS WITH THEM. THAT THEIR FRIENDS ARE NOT THERAPISTS. THEIR FRIENDS ARE THERE FOR SUPPORT. THEIR FRIENDS ARE THERE FOR DISTRACTION. IF THEY NEED TO DEAL WITH THEIR SUICIDAL THOUGHTS, THEY CAN TALK TO AN ADULT. THEY CAN TUBING THEIR PARENTS, THEY CAN TALK TO THEIR THERAPIST THERAPIST. -- THEY CAN TALK -- AND SO YOU WORK OUT A SAFETY PLAN AND THEN HAVE THE KID EXPLAIN IT TO THE PARENTS. THAT GIVES YOU AN IDEA ABOUT WHAT THEY REALLY GOT OUT OF THE DISCUSSION. YOU WANT TO GET PARENTAL FEEDBACK AND YOU WANT TO ASK BOTH OF THEM, BOTH THE PARENTS AND THE KIDS, WHAT MIGHT GET IN THE WAY OF THEM DOING THIS? AND THEN YOU EITHER FIGURE OUT HOW TO OVERCOME THOSE BARRIERS OR YOU MODIFY THE PLAN. AND YOU EITHER WANT TO REMOVE OR SECURE LETHAL AGENTS. WE DID A STUDY ABOUT ALMOST 20 YEARS AGO. IT WAS A PSYCHOTHERAPY STUDY AND BY MISTAKE, A QUESTION ABOUT AVAILABILITY OF GUNS GOT INTO THE RESEARCH PACKET. SO WE FIGURED WE WOULD LIKE AT IT AND IT TURNED OUT THAT THREE-FOURTHS OF THE PEOPLE WHO HAD GUNS IN THE HOME, AND WE ASKED THEM TO REMOVE THEM, DIDN'T. AND THE ONLY ONES WHO DID WERE WOMEN WHO WERE SINGLE PARENTS. AND THE ONES WHO WERE LEAST LIKELY TO WERE THOSE WHO HAD A DISCORDANT RELATIONSHIP WITH THEIR HUSBAND WHO HAD A SUBSTANCE ABUSE PROBLEM. SO IN RETROSPECT LIKE WE WERE TELLING PEOPLE TO GO TALK WITH THEIR ALCOHOLIC HUSBAND WITH WHOM THEY HAVE A BAD RELATIONSHIP ABOUT THE FACT THAT THEY HAVE TO GET THEIR GUN OUT OF THE HOUSE. IT'S LIKE THIS MUST HAVE SOUNDED REALLY STUPID. AND IT TURNS OUT THAT MOST PEOPLE WILL NOT REMOVE A GUN IF YOU DIRECT THEM TO DO IT. BUT THEY WILL STORE IT MORE SAFE SAFELY. SO, THE TREATMENT PLAN YOU WANT TO DEVELOP BASED ON THIS CHAIN ANALYSIS, AND THEN EACH DOMAIN THAT YOU IDENTIFY AS PROBLEMATIC, YOU CAN TALK ABOUT WHAT ARE SOME OF THE THINGS WE CAN DO TO COUNTER THAT? AND THEN YOU WANT TO ASK THEM TO RANK ORDER LIKE HOW PROBLEMATIC ARE THESE DIFFERENT THINGS FOR YOU? AND HOW LIKELY WOULD THIS BE THE WORK FOR YOU? BASED ON THAT MATRIX, THAT IS HOW YOU SET YOUR PRIORITIES. AND BASICALLY, WHAT YOU WANT TO KNOW IS WHAT'S GOING TO YIELD THE GREATEST RISK REDUCTION AND THE LEAST AMOUNT OF EFFORT? AND YOU WANT TO ALSO KNOW IS IT SOMETHING THAT CAN BE CHANGED? AND FINALLY, DO THEY WANT TO CHANGE IT? OR DO THEY HAVE THE ABILITY TO CHANGE IT? SO THIS KID, ONE OF THE THINGS HE SAID IS HE COULDN'T STAND THE PAIN. SO THAT WOULD LEAD YOU TO THINK ABOUT TEACHING HIM SOME DISTRESS TOLERANCE TECHNIQUES. HE WANTED TO EXPRESS HOSTILITY. SO LET'S LEARN SOME OTHER WAYS TO DO THAT. HE COULDN'T GENERATE ALTERNATIVE SOLUTIONS SO THIS IS A KID YOU MAY WANT TO TEACH PROBLEM-SOLVING SKILLS SO HE COULD. HE DRANK. WE DON'T KNOW HOW BAD A PROBLEM THAT IS. HE MAY NEED TREATMENT FOR ALCOHOL ABUSE. HE DESCRIBED A LOW MOOD. MAYBE HE NEEDS TREATMENT FOR DEPRESSION. WE HAVE TO FIND OUT. SO NOW I WANT TO SHARE WITH YOU SOMETHING THAT WE DEVELOPED. THIS IS NOT QUITE READY FOR PRIME-TIME BUT CLOSE. AND HERE WAS THE MOTIVATION. WE WERE WORKING ON A COGNITIVE BEHAVIORAL INTERVENTION FOR SUICIDAL ADOLESCENCE AND IT WAS A REALLY GOOD TEAM AND A GOOD INTERVENTION. IT NEVER ENDED UP IN A CLINICAL TRIAL FOR A LOT OF REASONS THAT I DON'T HAVE TO GO INTO NOW BUT ONE OF THE THINGS WE FOUND, WE DID AN OPEN TRIAL, 40% OF THE SUICIDAL EVENTS IN THESE KIDS OCCURRED WITHIN THE FIRST THREE WEEKS. AND THAT'S TRUE IN MOST CLINICAL TRIALS. SO THE QUESTION IS, SO IN OTHER WORDS YOU'RE GETTING KIDS IN THE HOSPITAL, YOU'RE GIVING THEM THE BEST THERAPISTS, THE BEST SUPERVISORS, AND THEY ARE NOT GETTING ENOUGH OF A DOSE OF WHATEVER IT IS YOU WANT TO GIVE THEM TO PREVENT THEM ACTING ON SUICIDAL URGES. SO WE FIGURED LIKE -- MAYBE YOU'RE INPATIENT UNITS ARE DIFFERENT. BUT THERE ISN'T MUCH THERAPY THAT GOES ON IN IN-PATIENT UNITS THESE DAYS. WHAT IF WE DEVELOPED A BRIEF INTERVENTION THAT WE COULD DELIVER ON THE IN-PATIENT UNIT AND DEVELOP AN APP THAT HAD THE SAFETY PLAN ON IT THAT THE KIDS COULD USE. WOULD THAT HELP THEM? WOULD THAT REDUCE THE RISK OF SUICIDE ATTEMPTS WHEN THEY LEFT THE HOSPITAL? AND SO, THE RATIONAL FOR AS SAFE AS POSSIBLE OR ASAP IS THAT THE PERIOD POST-DISCHARGE IS ONE OF THE HIGHEST RISK FOR REPEAT ATTEMPTS IN SUICIDES. THERE IS OFTEN A GAP BETWEEN DISCHARGE AND THE FIRST SESSION. AND EVEN WITH GOOD OUTPATIENT TREATMENT, THESE EVENTS OFTEN OCCUR EARLY ON BEFORE YOU HAVE A CHANCE TO DO VERY MUCH. SO WE THOUGHT, LET'S GO A LITTLE BIT UPSTREAM SEE IF WE CAN MAKE A DIFFERENCE. SO, TREATMENT AS USUAL IS THE INPATIENT CARE. THEY HAVE SKILLS GROUPS. THEY DO DEVELOP A SAFETY PLAN, AND THEY MAKE SURE THAT THE KIDS HAVE AFTERCARE. WALL WE DID WAS A CHAIN ANALYSIS. WE DEVELOPED A SAFETY PLAN ON THE BASIS OF THAT. AND THEN WE TAUGHT THEM SOME DISTRESS TOLERANCE AND EMOTION REGULATION SKILLS. AND WE USED MOTIVATIONAL INTERVIEWING TECHNIQUES TO ENCOURAGE FOLLOW-UP. SO, THE FIRST ITERATION OF THE INTERVENTION WAS WAY TOO LONG. IT TARGETED SLEEP, AND A LOT OF STUFF. WE COOPERATE GET IT DONE. SO, WE SHRUNK -- WE COULDN'T GET IT DONE SO WE SHRUNK IT DOWN. THEN WE DEVELOPED A SERIES OF PROTOTYPES OF THE APP, WHICH FINALLY ENDED UP BEING CALLED, BRITE, BASED ON FOCUS GROUPS. I DON'T LIKE THE NAME BUT THE KIDS LIKED IT. SO THIS IS BRITE. ONE OF THE THINGS THAT THEY TOLD US AND ONE OF THE FOCUS GROUPS IS, WE LIKE THE APP. WE LIKE THE SAFETY PLAN. BUT WHEN IT COMES TIME TO USE IT, WE ARE TOO DYSREGULATED. SO WE THOUGHT, LET'S GET THEM IN THE HABIT OF USING IT. WE TEXT THEM TRIES A DAY. WE CALL IT THE DAILY DOSE. AND -- TWICE A DAY. AND THEY RATE THEIR STRESS ON A SCALE OF 1-5, AND HOW THEY ARE FEELING. I DON'T LIKE EMOJIS BUT THEY LIKE THEM. AND THEN BASED ON THEIR LEVEL OF DISTRESS, IT TUNNELS THEM TO DIFFERENT INTERVENTIONS ON THE PHONE THAT ARE THINGS THAT THEY CHOSE TO LOAD ON BECAUSE THEY THOUGHT IT WOULD BE HELPFUL. SO, IT COULD BE POSITIVE MEMORIES. IT COULD BE REASONS FOR LIVING. THERE IS DISTRACTIONS, DEEP BREATHING, THE USUAL STUFF. PHOTOGRAPHS, PICTURE OF THEIR DOG. ONE OF THEM MADE A BUSINESS CARD THAT HE WAS GOING TO BE THE CEO OF A HIGH-TECH COMPANY. AND THEN FINALLY, WHEN THEY ARE REALLY HIGH-DISTRESSED, THERE IS THE OPTION TO CALL THESE DIFFERENT NUMBERS FOR EITHER THE THERAPIST NUMBER OR CRISIS TECHS AND SO ON. SO WE TREATED 20 KIDS OPENLY, TWO DIFFERENT GROUPS OF 10. WE DID THIS BETSY KIN ARD AND I DID THIS TOGETHER. SHE IS AT UNIVERSITY OF TEXAS SOUTHWEST. WE DID A TWO-SITE RCT OF 68 KIDS. THE ANALYSIS I'M GOING TO SHOW YOU, SO THERE WERE 68 KIDS WHO WERE RANDOMIZED. OF THOSE KIDS, THERE WERE THREE, ONE OF THEM NEVER GOT DISCHARGED. SO IF THE INTERVENTION IS UPPOSED TO KEEP THEM FROM ATTEMPTING AFTER DISCHARGE, YOU CAN'T TEST IT. PLUS THEY AREN'T ALLOWED TO USE THEIR PHONES ON THE UNIT. SO THEY NEVER GOT TO USE THE APP. AND THEN THERE WERE TWO OTHER KIDS WHO ATTEMPTED ON THE UNIT. SO WHEN YOU RUN THE ANALYSIS, INCLUDING EVERYBODY, ALTHOUGH THE RESULTS ARE POSITIVE, THEY ARE IN THE RIGHT DIRECTION, THEY AREN'T SPECIFICALLY SIGNIFICANT. IF YOU EXCLUDE THOSE THREE KIDS AND JUST LOOK AT WHAT HAPPENED AFTER DISCHARGE, THEY ARE SIGNIFICANT. MY POINT BEING IS THAT THIS IS STILL PRELIMINARY. IF YOU PUT IN THREE OR TAKE OUT THREE IT CHANGES THE LEVEL OF SIGNIFICANTS. YOU KNOW YOU HAVE MORE WORK TO DO. BUT I JUST WANT TO EXPLAIN THAT THERE IS A RATIONAL FOR WHAT I'M GOING TO SHOW YOU. SO THESE KIDS WERE VERY WELL MATCHED. AND YOU CAN SEE VERY HIGH PROPORTION OF THEM MADE A PREVIOUS ATTEMPT. ALMOST ALL OF THEM WERE FEMALE AND WHITE WHICH AGAIN THAT IS SOMETHING WE NEED TO TEST THIS IN A MORE DIVERSE POPULATION. AND THEY WERE QUITE -- HAD VERY HIGH SCORES ON ANXIETY AND DEPRESSION. THIS IS THE VARIATE THING AND FINDINGS IN TERMS OF THE HAZARD OF AN ATTEMPT. AND WHAT CAN YOU SEE IS THAT THE ASA-D HAVE A LOWER RISK, ALTHOUGH THIS DIFFERENCE IS NOT STATISTICALLY SIGNIFICANT. NOW WHEN WE CONTROLLED FOR THE OTHER VARIABLES THAT WERE RELATED TO ATTEMPT, THEN THE RESULTS WERE STATISTICALLY SIGNIFICANT. AND THE POINT IS THAT THIS IS PROMISING BUT IT CLEARLY NEEDS A BIGGER TRIAL THAN THIS. AND WE ALSO FOUND THE IMPACT OF THE INTERVENTION WAS NOD RATED BY A HISTORY OF A PREVIOUS ATTEMPT. AND THAT THE KIDS WHO HAD HAD A PAST ATTEMPT, THE DIFFERENCES WERE STATISTICALLY SIGNIFICANT. SO THAT IS GOOD BECAUSE THOSE ARE THE KIDS THAT ARE PROBABLY AT HIGHEST RISK. NOW IN TERMS OF THE APP, THE KID ABOUT THREE-FOURTHS OF THEM USED IT WHO WERE IN THE ASAP GROUP. AND THEY USED IT AN AVERAGE OF ALMOST 30 TIMES. AND WHAT WE FOUND IS A TREND TOWARDS A DECLINE IN SUICIDAL IDEATION THE MORE THEY USED THE APP. AND THEY ALSO -- I DON'T KNOW WHERE THIS IS BUT -- WE ALSO FOUND THAT THEIR REASONS FOR LIVING WENT UP AS WELL. SO THAT SUGGESTS THAT THE MORE THEY USED THE APP, THE BETTER THEY DID. AGAIN IT'S HARD TO DISENTANGLE WHAT IS WHAT THERE. THEY WERE QUITE SATISFIED WITH IT. WE GOT FEEDBACK LIKE KIDS SAYING I HAD REALLY BAD ANXIETY. I WAS ABLE TO CALM MYSELF DOWN. I USED GROUNDING AND MINDFULNESS MINDFULNESS. AND SO QUALITATIVELY THE KIDS SEEMED TO LIKE IT. AND HE SAYS I REALLY LIKE HOW YOU CHECK IN WITH YOURSELF, YOUR TEMP IS RISING AND YOU DON'T EVEN KNOW IT. YOU CAN STOP AND CHECK IN. AND SO THEY ACTUALLY, ONE OF THE FEEDBACKS IS THEY WANTED TO BE TEXTED MORE OFTEN THAN TWICE A DAY. GO FIGURE. SO, OUR CONCLUSIONS FROM THIS ARE THAT ASA. AND BRITS FEASIBLE AND LOGICAL AND AS A COMBINED TREATMENT AS A BRIDGE FROM IN-PATIENT TO OUT-PATIENT. IT WAS WELL ACCEPTED. THERE IS SOME PRELIMINARY EVIDENCE OF EFFICACY AND THE QUESTION IS, CAN YOU DISSEMINATE THIS AND SHOW THAT IT WORKS? SO NOW I'D LIKE TO TALK A LITTLE BIT ABOUT WHAT MAY BE COMING UP œAND I WANT TO TALK ABOUT JOE FRANKLIN'S INTERVENTION WHICH IS A GAME THAT IS BASED ON MATT KNOCKS STUDIES OF SUICIDAL BEHAVIOR. A STUDY THAT I DID WITH MARCEL JUST, AND I'LL TELL BUT THAT. AND THEN THE USE OF FMRI FEEDBACK TO MODIFY AMYGDALA RESPONSE. I NIGHTED DANNY KLINE WROTE A -- I NOTICED DANNY KLINE WROTE POSITIVE COMMENTS ABOUT IT. SO MATT KNOCK PROBABLY THE, ONE OF THE LEADING SUICIDE RESEARCHERS WORKING TODAY, VERY NICE GUY, VERY CREATIVE AND HAS TRAINED A CADRE OF TERRIFIC PEOPLE. JOE FRANKLIN BEING ONE OF THEM. SO, MATT DEVELOPED SOMETHING CALLED, AN IAT FOR SUICIDE. IMPLICIT ASSOCIATION TEST. THE IAT WAS ORIGINALLY DEVELOPED TO LOOK AT RACISM. YOU SHOW PEOPLE IMAGES AND THEN YOU HAVE THEM MAKE CERTAIN RESPONSES AND BASED ON THE SPEED OF THE RESPONSE, YOU CAN GET AN IDEA OF THEIR IMPLICIT BIAS. AND SO MATT GOT THE IDEA, WHAT ABOUT THEIR BIAS TOWARDS OR AWAY FROM SUICIDE? OR SELF CUTTING? AND SO IF YOU SHOW PEOPLE IMAGES OR WORDS RELATED TO SUICIDE AND THEN BASICALLY YOU HAVE THEM PUSH A BUTTON ON A COMPUTER THAT SAYS ME OR NOT ME, THE SPEED WITH WHICH THEY PUSH ME VERSUS NOT ME ON SUICIDE DIFFERENTIATES PEOPLE WHO ARE LIKELY TO GO ON AND MAKE A SUICIDE ATTEMPT. THE IDEA BEING THAT THE PEOPLE WHO ARE AT RISK ASSOCIATE SUICIDE WITH SELF. NOW A SECONDARY FINDING THAT HE HADN'T DONE AS MUCH WITH, IS THAT THEY ALSO ASSOCIATE THEMSELVES WITH THINGS THAT ARE NEGATIVE. SO JOE GOT THE IDEA, LET'S INVENT A GAME WHERE PEOPLE WILL BE PRESENTED IMAGES OF SUICIDAL OR SELF-CUTTING, AND THEY'LL GET POINTS IF THEY ASSOCIATE IT WITH SOMETHING NEGATIVE, SOMETHING DISGUSTING. AND AT THE SAME TIME, WORDS RELATED TO SELF, THEY'LL GET POINTS IF THEY ASSOCIATE IT WITH SOMETHING HASSATIVE. AND HE DID THREE TRIALS, RECRUITED PEOPLE FROM THE INTERNET AND WAS ABLE TO SHOW DECLINES IN SUICIDAL IDEATION AND SELF-HARM AND SUICIDAL PLANS. I THINK ONE OF THEM, TWO OF THEM SHOWED DECLINE IN BEHAVIOR. AND THIS LASTED AS LONG AS THEY DID IT WHEN THEY FOLLOWED THEM UP THE EFFECTS FADED. BUT STILL, IT'S LIKE I SPENT ALL THESE YEARS TALKING TO PEOPLE AND HERE THEY PLAY A GAME AND IT GOES AWAY. BUT YOU KNOW, THIS COULD BE A USEFUL -- IT'S JUST CONFIRMATORY OF THIS THEORY. SO NOW I'M GOING TO TELL YOU ABOUT WHAT IS RIGHT NOW MY FAVORITE STUDY. THERE IS A GUY AT CARNEGIE MELLON AND PIT WHERE I AM AND CARNEGIE MELLON ARE CONTIGUOUS AND MY OFFICE IS ACTUALLY CLOSER TO CORN GHEE MELON THAT IT IS TO MY -- CARNEGIE MELLON THAN IT IS TO MY CHAIRMAN'S OFFICE. THIS PERSON, MARCEL, A VERY CREATIVE COGNITIVE PSYCHOLOGIST, GAVE A TALK A NUMBER OF YEARS AGO IN WHICH HE WAS STUDYING THE NEUROSIGNATURES OF LANGUAGE. HE ORIGINALLY WANTED TO KNOW DO NOUNS AND VERBS LOOK THE SAME WHEN YOU HAVE SOMEBODY THINK ABOUT IT? HOW ARE THEY REPRESENTED? IN THE BRAIN? AND WHAT HE FOUND IS THAT IF HE GAVE PEOPLE A LIST OF 40 WORDS, HE COULD TELL WHICH OF THOSE 40 WORDS THEY WERE THINKING ABOUT BASED ON THEIR NEUROSIGNATURE MUCH BETTER THAN CHANCE. AND YES, HE DOES HAVE A GRANT FROM DARPA. BUT HE ALSO THEN COLLABORATED WITH ONE OF OUR COLLEAGUES AT PIT TO LOOK AT PEOPLE WHO HAD HIGH-FUNCTIONING AUTISM AND THEN NEUROTYPICAL PEOPLE. AND HE GAVE THEM WORDS RELATED TO RELATIONSHIPS. AND ON THE BASIS OF THEIR ACTIVATION PATTERNS, HE COULD COMPLETELY DISCRIMINATE BETWEEN THE PEOPLE WITH AUTISM AND THOSE WHO WERE NEUROTYPICAL. SO I WENT UP TO HIM AFTERWARDS AND SAID, WOULD YOU BE INTERESTED IN DOING SOMETHING ON SUICIDE? AND SO, I TALKED TO MATT KNOCK AND THEY HAD DONE A STUDY WITH A SUICIDE TROUPE AND HAD A LIST OF WORDS, WHICH ACCORDING TO WHAT HE SAID IS THAT IT DIDN'T WORK OUT THAT WELL, BUT WE HAD WORDS ANYWAY. WHAT WE DID IS WE GOT PEOPLE WHO WERE YOUNG ADULTS WHO HAD SERIOUS SUICIDAL IDEATION AND A GROUP OF HEALTHY CONTROLS, AND THEY WOULD GO INTO THE SCANNER AND THEY WOULD THINK ABOUT EACH WORD FOR ABOUT THREE SECONDS AND THEN WE WOULD USE MACHINE PATTERNS TO TRY AND SEPARATE THE TWO GROUPS. AND WE WERE ABLE TO -- SO WE HAD ONE -- WE HAD 17 PAIRS WHERE WE HAD REALLY GOOD DATA. AND THEN WE HAD ANOTHER 34, OR SOMETHING LIKE THAT, WHERE THE DATA WAS NOISIER. SO WE USED THE ALGORITHM ON THE 34 AND WE WERE AT A VERY HIGH LEVEL OF ACCURACY, ABLE TO TELL WHO WAS AN IDEA ART AND WHO WASN'T. AND WITHIN THE IDEA 8ORS, WE COULD TELL WHO HAD MADE AN ATTEMPT. AND THEN ON THE SECOND GROUP THAT WERE NOISIER, WE WERE ABLE TO CLASSIFY THEM WITH HIGH DEGREE OF ACCURACY. -- AND THE ANTERIOR CINGULATE. WE DEBRIEFED THESE PEOPLE AFTERWARDS AND TRANSCRIBED WHAT THEY THOUGHT ABOUT ON EACH WORD. AND IT WAS VERY INTERESTING ESPECIALLY IN LIGHT OF THE FACT THAT THE ANTERIOR CINGULATE WAS ONE OF THE THINGS THAT DIFFERENTIATED THE GROUPS. IF YOU ASKED A SUICIDAL PERSON WHAT THEY THOUGHT ABOUT THE WORD, FUNERAL, THEY WOULD SAY MY FUNERAL. WHEREAS A HEALTHY PERSON WOULD SAY, YOU HAVE TO WEAR AN ITCHY SUIT. YOU'RE OUT IN THE CEMETERY. AND SO THERE WAS MUCH MORE SELF-REFERENCE, IDENTIFICATION WITH SELF, WITH THE WORDS RELATED TO SUICIDE. AND SOME OTHER WORDS, THAN IN THE NON-SUICIDAL GROUP WHICH IS VERY CONSISTENT WITH MATT KNOCKS IAT. AND SO, ANYWAY, FOR THOSE WHO KNOW SOMETHING ABOUT BRAINS, THESE ARE THE AREAS OF THE BRAIN THAT WERE DIFFERENT BETWEEN THE TWO GROUPS. AND JUST TO GIVE YOU SOME IDEA THAT THESE THINGS AREN'T PERFECT BUT THAT THESE ARE THE DIFFERENTIAL RESPONSES IN CERTAIN BRAIN REGIONS. AND ALSO THIS IS COMPARING PEOPLE WHO ARE ATTEMPTERS AND NOT. THEY HAD A DIFFERENT RESPONSE TO THE WORD, TO SAY THE WORD, DEATH. NOW IT IS INTERESTING THAT MARCEL ALSO IS ABLE TO INDEX WHAT EMOTIONS THEY ARE THINKING ABOUT WHEN THEY ARE THINKING ABOUT THESE WORDS, BECAUSE WE HAVE DONE ANOTHER STUDY AND IDENTIFIED THE NEUROSIGNATURES OF EMOTIONS. AND THE ATTEMPTERS, COMPARED TO THOSE WHO JUST HAD IDEATION, THE ATTEMPTERS HAD MUCH LESS DISTRESSING EMOTIONS WHEN THEY THOUGHT ABOUT DEATH THAN THE IDEATOR. WHICH MAKES SENSE IN A WAY BUT IT IS KIND OF SCARY. AND WE ALSO FOUND A CORRELATION WITH THE DEGREE IN WHICH THEY DEVIATED FROM NORMAL AND THE SEVERITY OF SUICIDAL IDEATION. SO WE GOT AT A GOOD SCORE. WE'LL SEE IF THE GOVERNMENT STAYS OPEN. WE WANT TO DO A PROSPECTIVE STUDY AND REPEAT THESE. ANDY WOO ARE ALSO WANTING TO BUILD A BIGGER VERSION OF THE IAT TO SEE IF WE CAN LOOK PROLIFERALLY AND SEE IF WE CAN FIND THE SAME CORRELATION. AND FINALLY, THIS STUDY BY KIM YOUNG, A BRILLIANT YOUNG INVESTIGATOR. AND SHE HAS DONE A STUDY WHERE SHE HAS PEOPLE -- THEY HAVE LIKE A LITTLE THERMOMETER WHEN THEY ARE IN THE SCANNER SO THEY CAN GET FEEDBACK ABOUT HOW MUCH AMYGDALA ACTIVATION THEY HAVE. AND SHE TRAINS THEM TO THINK ABOUT POSITIVE AUTOBIOGRAPHICAL MEMORIES AND INCREASE THEIR AMYGDALA ACTIVATION. SHE DID A SMALL CLINICAL TRIAL THAT SHOWED A REDUCTION IN DEPRESSION. AND SO ONE OF THE THINGS I WAS THINKING ABOUT IS, MAYBE YOU COULD TAKE SOME TECHNIQUE LIKE THIS AND PAIR IT WITH WHAT MARCEL AND I ARE DOING AND SEE WHETHER OR NOT YOU CAN GET PEOPLE TO CHANGE THEIR ATTITUDES IN THE WAY THEY ARE THINKING ABOUT SUICIDE AND DEATH. ANYWAY, SHE WAS ABLE TO SHOW THAT THEIR DEPRESSIVE SYMPTOMS, THE CHANGE WAS MEDIATED BY THE DEGREE TO WHICH THEY WERE ABLE TO CHANGE AMYGDALA ACTIVATION. SO, THAT CONCLUDES MY REMARKS. I'D LIKE TO THANK NIMH FOR THEIR SUPPORT AND FOR INVITING ME. JANE PEARSON AND JOEL SHERRILL, OUR PROGRAM OFFICERS FOR THE ASAP STUDY. THE INPATIENT UNIT WHO HELPED US TO RECRUIT THEM. THE PATIENTS AND FAMILIES. AND THE DEZUDI. WHO HELPED US DESIGN THE APP. THANK YOU VERY MUCH. [ APPLAUSE ] >> THANK YOU VERY MUCH. I'M GOING TO USE ORGANIZERS PER ROGGATIVE TO SHARE A STORY WITH YOU. -- PREROGATIVE -- THROUGHOUT MY CAREER, IN RESEARCHING MOOD DISORDERS, I HAD INTRUSIVE IMAGE IMAGES OF DOCTOR BRENT, THE FIRST TIME YOU ARE HEARING THIS. WHAT WOULD DAVID BRENT HAVE SAID ABOUT THIS? OR HOW WOULD HE HAVE COMMENTED ABOUT IT? SO I THOUGHT IT IS TIME NOW TO LAUNCH THE UNIT TO BRING HIM HERE AND GET HIS THOUGHTS FIRSTHAND. WE ARE VERY GRATEFUL FOR THE TALK AND IT IS VERY ENCOURAGING TO SEE THAT SO MUCH RESEARCH IS BEING DONE AND SO MUCH IS UNDERSTOOD NOW IN SUICIDE RESEARCH. CAN I START WITH A QUESTION? SO, AND YOU HAVE MENTION TODAY PARTLY BUT I JUST WANTED TO ASK EXPLICITLY ABOUT IT. DO YOU THINK THERE IS AN INCREASE IN THE RATES OF SUICIDE? AND IF THERE IS A PROPER SECULAR TREND, WHAT DO YOU THINK MIGHT BE THE UNDERLYING REASONS FOR IT? >> THANKS. EVERYBODY HEARD THE QUESTION? WHY IS THE SUICIDE RATE GOING UP? I WAS INVITED TO SPEAK ABOUT THAT ON 60 MINUTES. AND I SAID THAT I DON'T KNOW. SO I DON'T THINK YOU SHOULD INTERVIEW ME. [ LAUGHS ] SO, I MEAN FOR EXAMPLE, WE THOUGHT HAD SOMETHING TO DO WITH THE BLACK BOX WARNING. DECLINE IN USE OF ANTI-DEPRESSANTS BUT THE LEVEL OF ANTI-DEPRESSANT USE HAS COME BACK TO WHAT IT WAS BEFORE. THE RATE HASN'T COME DOWN. PLUS THAT DOESN'T EXPLAIN THE INCREASE IN MIDDLE-AGED MEN WHERE THE CHANGE IN USE OF ANTI-DEPRESSANTS HAVEN'T BEEN ANY CHANGE. SOME PEOPLE SAID MAYBE IT HAS SOMETHING TO DO WITH THE OPIOID EPIDEMIC. IT COULD BE. IT IS AFFECTING THEIR PARENTS AND FAMILIES. NOBODY REALLY KNOWS. I ACTUALLY THINK THAT WE OUGHT TO GO BACK TO BASICS AND WE NEED TO DO ANOTHER PSYCHOLOGICAL AUTOPSY STUDY TO FIND OUT WHAT THESE KIDS ARE REALLY LIKE. AND THAT MIGHT GIVE US SOME CLUES ABOUT WHAT PARTICULARLY YOUNGER KIDS, WHAT IS GOING ON. BUT I DON'T KNOW. >> THANK YOU. WE WILL TAKE SOME QUESTIONS FROM THE AUDIENCE. WE HAVE ANOTHER 5 OR 6 MINUTES. WHO WOULD LIKE TO START? WHO HAS A QUESTION? >> [ OFF MIC ] >> SO THE QUESTION IS, PERHAPS SOCIAL MEDIA USE OR THE INTERNET IS CONTRIBUTING TO THIS RISE. I THINK THAT -- I MEANT TO SAY THAT BUT I FORGOT. SO THANK YOU. BUT I THINK IT'S A REASONABLE CONSIDERATION. IT'S JUST, YOU DON'T WANT TO BLAME THAT AND THEN STOP LOOKING. BUT I THINK IT IS VERY LIKELY THAT IT COULD BE CONTRIBUTING, YES. >> [ OFF MICROPHONE ] NOT ONLY CONTENT OF SOCIAL NETWORKING BUT ALSO THE TIMING. MOST KIDS STAY UNTIL MIDNIGHT DOING WHATEVER, GOOD OR BAD, I DON'T CARE, BUT JUST UNTIL MIDNIGHT, WHICH MEANS THEY WAKE UP SLEEP DEPRIVED, WHICH ALL THE MULTIINDICATING FACTOR. HOW CAN WE ADDRESS THAT? >> ACCORDING TO THE DATA, I THINK YOU HAVE TO GET PARENTS TO BE MORE ASSERTIVE WITH THEIR KIDS ABOUT -- USING A COMPUTER AND SOCIAL MEDIA, IT'S NOT A RIGHT. IT'S A PRIVILEGE. AND IF IT'S AFFECTING THE KID'S HEALTH THEN YOU HAVE TO STEP IN AND -- I REALIZED IT ISN'T CONSISTENT WITH THAT TYPE OF PARENTING THAT HAS BECOME THE MODE, BUT I THINK PARENTS HAVE TO STEP IN AND SET RULES WITH KIDS ABOUT THAT BEFORE THEY HIT PUBERTY. FOR SOME TOO LATE. >> SO WHO WOULD LIKE TO GO NEXT? >> THANK YOU. IT STRIKES ME AS INTERESTING THAT ASKING A PATIENT ABOUT SUICIDAL DOES NOT INCREASE THE RISK AND THEN I CONTRAST THAT WITH INCREASE OF RISK OF CONTAGION AND I'M THINKING ABOUT THAT. WHAT IS THE CURRENT THINKING OF THE DIFFERENCE IN THAT? >> SO, I THINK IT HAS TO DO WITH CONTEXT. IF YOU LOOK AT THE -- MADELINE GOULD DID A STUDY WHERE SHE LOOKED AT SINGLETON SUICIDE VERSUS SUICIDE THAT OCCURRED IN CLUSTERS. FIRST OF ALL, WHAT SHE FOUND IS THAT THE SUEDES -- THE CLUSTERS DID NOT KNOW EACH OTHER THAT WELL. THEY WERE NOT CLOSE FRIENDS. SECONDLY, SHE FOUND THAT THE MEDIA PUBLICITY FOR THE CLUSTERS, SHE WAS LOOKING AT WHAT THE MEDIA PUBLICITY WAS FOR THE FIRST SUICIDE AND SHE FOUND THAT THERE WERE MORE FRONT-PAGE HEADLINES, MORE TEXT, MORE DESCRIPTION OF THE METH, LESS DESCRIPTION OF WHERE YOU COULD GO FOR HELP, LESS FRAMING IT AS SOMETHING CLINICAL. AND SO JUST ONE OTHER THING AND THEN I'LL SUM UP, BUT WE DID A STUDY LOOKING AT THE IMPACT OF SUICIDE ON THE FRIENDS AND FRIENDS OF FRIENDS OF SUICIDE VICTIMS, EXPECTING THE CLOSER THEY WERE TO THE VICTIM THE MORE LIKELY THEY WOULD BE TO IMITATE. WHAT WE FOUND WAS THAT EVEN THOUGH THE FRIENDS OF SUICIDE VICTIMS WERE AT VERY HIGH RISK BECAUSE OF A SORT OF MATING, THEY HAD HALF THE RISK OF MAKING THE ATTEMPT. IT WASN'T STATISTICALLY SIGNIFICANT BUT IT WAS IN THAT DIRECTION. AND WHEN WE ASKED KIDS ABOUT THAT, THEY SAID, I WAS ABLE TO SEE FIRSTHAND THE COST OF A SUICIDE, WHAT IT DID TO ME, WHAT IT DID TO THE FAMILIES. AND NO MATTER HOW SUICIDAL I WOULD BE, I WOULD NOT DO THIS. AND SAYS I THINK THAT WHAT THE DIFFERENCE IS IS THAT WHEN YOU'RE ASKING SOMEBODY IN A CLINICAL SITUATION, YOU'RE SERIOUS, YOU'RE WORRYING ABOUT -- IT'S IN THE GUYS -- NOT GUYS, BUT ATTEMPT TO HELP THEM, WHEREAS THE OTHER IS PERHAPS APPEALING TO THE IDEA THAT I'LL BE FAMOUS, I'LL GET BACK AT PEOPLE. SOMETHING LIKE THAT. SO IT'S APPEALING TO OTHER INDUCEMENTS FOR SUICIDAL BEHAVIOR. >> I WAS WONDERING ABOUT THE APP. IT IS MEETING PEOPLE WHERE THEY ARE APP. AND I WAS LOOKING YESTERDAY WITH THE TEEN TO TRY AND FIND ONE THAT -- WHEN YOU DO YOUR SNAPSHOTS DOES IT ALSO LOOK AT THE TRENDING OVER TIME? SO NOW YOU HAVE A LOT OF COLLECTIVE DATA TWICE A DAY. DOES IT SAY, OKAY, WE ARE LOOKING ATROPHY MAILS. WE KNOW DIFFERENT -- LOOKING ATROPHY MAILS AND WE ARE LOOKING AT DIFFERENT CYCLES, DIFFERENT THINGS. DO YOU END UP WITH CYCLING INFORMATION THAT SHOWS TRENDS? >> YEAR NOT SURE ON THAT. I THINK PART OF IT IS, WHAT WE WILL DO IS REVISE THE APP SO WE CAN GET BETTER DATA FROM IT. SO, PART OF IT IS IT WAS DIFFICULT TO GET ALL THAT DATA AND IT'S NOT THAT BIGAISE SAMPLE EVEN THOUGH YOU'RE RIGHT, IT'S A LOT OF DATA PER KID. BUT IT'S A REALLY GOOD SUGGESTION. >> OTHER QUESTIONS? THAT'S GOOD BECAUSE NOW WE HAVE A 15 MINUTE BREAK. PLEASE TRY TO BE BACK AT 10:13 DR. BRENT WANTED TO SAY A FEW THINGS AND THEN I GET TO INTRODUCE DR. HOROWITS. >> THANK YOU. I JUST SAID SOMETHING THAT PEOPLE POSSIBLY MISUNDERSTOOD OR I DIDN'T EXPRESS MYSELF CLEARLY. I THINK SCREENING IS VERY IMPORTANT. I WAS ONLY TRYING TO SAY THAT IN YOUNGER KIDS, IT TURNS OUT THAT LETHAL -- THAT RESTRICTION OF MEANS IS SOMETHING THAT PEOPLE DON'T USUALLY THINK ABOUT. I THINK SCREENING IS A REALLY IMPORTANT COMPONENT OF OUR ATTEMPT TO TRY AND REDUCE THE SUICIDE RATE. AND I JUST DIDN'T WANT THOSE REMARKS TO BE TAKEN OUT OF CONTEXT. ESPECIALLY NOW THAT LISA WILL TALK TO US ABOUT THAT. SORRY ABOUT THAT. >> NO APOLOGY NEEDED WHATSOEVER. IT IS MY PLEASURE TO INTRODUCE DR. HOROWITS WHO IS REALLY OUR EXCELLENT COLLEAGUE. SHE IS A STAFF SCIENTIST AT THE NIMH INTRAMURAL RESEARCH PROGRAM. AND THE SHE SERVES AS SENIOR ATTENDING WITH A SPECIALTY IN PEDIATRIC PSYCHOLOGY ON THE PSYCHIATRY CONSULTATION LIAISON SERVICE IN THE OFFICE OF THE CLINICAL DIRECTOR. DR. HOROWITS RECEIVED HER BACHELOR'S DEGREE FROM TUFTS UNIVERSITY AND AFTER OBTAINING HER DOCTORATE IN CLINICAL PSYCHOLOGY FROM THE GEORGE WASHINGTON UNIVERSITY, SHE COMPLETE AID PEDIATRIC FELLOWSHIP AT BOSTON CHILDREN'S HOSPITAL AS WELL AS A HEALTH SERVICES RESEARCH FELLOWSHIP IN THE CLINICAL EFFECTIVENESS PROGRAM AT HARVARD MEDICAL SCHOOL WHERE SHE OBTAINED A MASTER'S DEGREE IN PUBLIC HEALTH. MAJOR FOCUS OF DR. HOROWITS'S RESEARCH HAS BEEN IN THE AREA OF SUICIDE PREVENTION AND DETECTION. SHE WAS THE LEAD PRINCIPAL INVESTIGATOR ON THE DEVELOPMENT OF TWO SUICIDE SCREENING INSTRUMENTS FOR THE PEDIATRIC EMERGENCY DEPARTMENT, THE RISK OF SUICIDE ASSESSMENT QUESTIONNAIRE, AND THE ASK SUICIDE SCREENING QUESTIONS. A TOOL CREATED TO INCLUDE PEDIATRIC MEDICAL AND SURGICAL PATIENTS IN THE EMERGENCY DEPARTMENT SETTING. LISA HOROWITZ IS ALSO THE LEAD PRINCIPAL INVESTIGATOR ON SEVERAL OTHER INSTRUMENT DEVELOPMENT STUDIES THAT WILL INCLUDE CONCERN WITH INTELLECTUAL DISABILITIES AND PEDIATRIC AND ADULT INPATIENTS. THIS IS DR. LISA HOROWITZ. WELCOME. [ APPLAUSE ] >> THANK YOU VERY MUCH. THANK YOU DR. TOBIN AND DR. ARGYRIS STRINGARIS FOR INVITING ME TO SPEAK TODAY. I FEEL SO PRIVILEGED TO BE HERE TO SPEAK TO YOU NOT ONLY ABOUT AN AREA THAT I FEEL VERY PASSIONATELY ABOUT AND IS A TERRIBLE PUBLIC HEALTH CRISIS, BUT ALSO BECAUSE I BELIEVE THAT EVERY ONE OF US IN THIS ROOM CAN MAKE A DIFFERENCE IN THIS EVER-INCREASING SUICIDE RATE. BEFORE I GET STARTED, I JUST BECAUSE I WORK FOR THE GOVERNMENT, I SHOULD SAY THESE VIEWS ARE MINE AND DON'T NECESSARILY REPRESENT THE GOVERNMENT. AND I HAVE NO CONFLICTS DISCLOSE, OTHER THAN I THAT YOU WENT EXCITED TO BE TOLD I WAS FOLLOWING DAVID BRENT IN MY SPEECH. HE'S A TOUGH ACT TO FOLLOW BUT I'LL DO THE BEST I CAN. [ LAUGHS ] FIRST CAN I SEE A SHOW OF HANDS? I WANT TO GET AN IDEA OF WHO YOU ARE IN THE AUDIENCE. HOW MANY PEOPLE ARE MENTAL HEALTH CLINICIANS? SO A LOT OF HANDS ARE GOING UP JUST BECAUSE THESE TWO SIDES CAN'T SEE EACH OTHER. HOW ABOUT MEDICAL CLINICIANS? NOT THAT MANY. WORK IN THE EMERGENCY DEPARTMENT? ANYBODY? IN-PATIENT MEDICAL SURGICAL UNITS? OUT-PATIENT CLINICS? SO I JUST WANTED TO GET AN IDEA. AND HOW MANY PEOPLE HERE HAVE BEEN TOUCHED BY SUICIDE IN SOME WAY EITHER PROFESSIONALLY OR PERSONALLY OR IN SOME WAY? OKAY. SO MANY, MANY HANDS ARE GOING UP. AND THAT HAPPENS IN EVERY TALK THAT I GIVE. SUICIDE IS RELATIVELY RARE EVENTED BUT THE RIPPLE EFFECTS ARE ENDLESS. AND I JUST WANTED TO TALK ABOUT HOW I FIRST GOT INTERESTED IN CREATING SUICIDE RISK SCREENING TOOLS FOR SUICIDE PREVENTION. WHEN I WAS IN THE EARLY 90s, WHEN I WAS A YOUNG TRAINEE UP IN BOSTON, I WAS DOING MY EMERGENCY DEPARTMENT ROTATION. AND ONE OF MY FIRST CASES THAT CAME IN WAS A YOUNG MAN AND HE WAS BROUGHT IN BY HIS FRIENDS. HE WAS IN HIS EARLY 20s. HE MOST LIKELY HAD UNTREATED BIPOLAR DISORDER. AND I ASSESSED HIM AND THEN WENT TO TALK TO MY SUPERVISOR AND MY SUPERVISOR SAID, WELL, WE WILL HAVE TO SEND HIM TO A PSYCHIATRIC UNIT BECAUSE HE IS DEFINITELY AT RISK FOR HARMING HIMSELF. SO YOU NEED TO GO TELL HIM THAT. WHEN YOU TELL HIM, DON'T TELL HIM UNTIL THE AMBULANCE ARRIVES BECAUSE HE WILL BE REALLY UPSET ABOUT IT AND SO MAKE SURE THE EMTs ARE THERE. I SAID, OKAY. I WAS REALLY NERVOUS. IT WAS THE FIRST TIME I WAS GOING TO TELL SOMEONE THEY WERE BEING SENT TO A PSYCHIATRIC UNIT. SO, THERE WAS A SECURITY GUARD STANDING OUTSIDE OF HIS ROOM OR SITTING OUTSIDE HIS ROOM AND I WAITED AND THE EMS SHOWED UP AND SO, ME AND THE NURSE AND THE TWO EMTs AND THE SECURITY GUARD WERE THERE AND I WENT IN AND I SAID, Mr. JONES, WE ARE REALLY CONCERNED ABOUT YOUR SAFETY AND SO WE ARE GOING TO SEND YOU TO A PSYCHIATRIC HOSPITAL SO THAT YOU CAN RECEIVE TREATMENT. AND HE SAID, OKAY. LET ME GET MY COAT. I THOUGHT, OKAY. THAT DIDN'T GO SO BADLY. HE WENT OVER AND GRABBED HIS COAT AND PUT HIS HAND IN HIS POCKET AND PULLED OUT A FIST FULL OF PILLS AND INGESTED THEM. AND I WAS JUST SO TAKEN ABACK THAT TO WATCH SOMEBODY DO THAT BUT TO WATCH SOMEBODY DO THAT IN A HOSPITAL -- WHERE WE ARE SUPPOSED TO KEEP PEOPLE SAFE. SO, THIS REALLY LAUNCHED MY INTEREST IN HOW DO WE DETECT SUICIDE RISK AND HOW DO WE KEEP PEOPLE SAFE, ESPECIALLY IN THE MEDICAL SETTING? SO I WAS TAUGHT TO START MY TALK WITH MY TAKE HOME MESSAGE AND START MY SLIDES WITH MY LAST SLIDE. SO I'M GOING TO BASICALLY, MY TAKE HOME MESSAGE WILL BE ADVOCATING IF ARE UNIVERSAL SCREENING FOR ALL KIDS AND ALL YOUTH IN MEDICAL SETTINGS. AND TO REALLY ASK DIRECTLY ABOUT SUICIDE. CLINICIANS REQUIRE POPULATION-SPECIFIC AND SITE-SPECIFIC TOOLS. SO IF YOU'RE NOT GOING TO USE ADULT TOOLS ON KIDS UNLESS THEY HAVE BEEN TESTED IN THAT WAY. AND IF YOU'RE GOING TO USE A TOOL DEVELOPED IN THE EMERGENCY DEPARTMENT, THEN IT SHOULD BE TESTED IN THE OTHER PLACES YOU'RE GOING TO USE IT. I'M GOING FORWARD A THREE-TIERED CLINICAL PATHWAY OF SCREENING THAT WE THINK HAS BEEN EFFECTIVE, AND IT IS GOING TO START WITH A 20-SECOND BRIEF SCREEN. AND THEN A CRITICAL FOLLOW-UP OF THE SCREEN WILL BE A BRIEF SUICIDE SAFETY ASSESSMENT, WHICH I WILL TALK MORE ABOUT. AND THAT WILL DETERMINE WHETHER OR NOT THE PATIENT NEEDS A FULL SAFETY ASSESSMENT. AND ULTIMATELY, ALL PATIENTS THAT SCREEN POSITIVE ON SCREENING TOOLS SHOULD BE DISCHARGED WITH A SAFETY PLAN AS DR. BRENT WAS TALKING ABOUT. RESOURCES AND TALK ABOUT MEANS RESTRICTION AND SAFE STORAGE. SO, MY TALK IS GOING TO SHIFT A LITTLE BIT INTO THE MEDICAL SETTING, HOW DO WE IDENTIFY RISK IN MEDICAL SETTING? SO IF WE LOOK AT MORTALITY FROM MEDICAL CAUSES, AND IF I SHOW YOU TWO PERIODS, ONE A PEAK PERIOD ENDING IN 1995 AND A PEAK PERIOD THAT IS CURRENT, YOU CAN SEE THE STRIDES WE MADE IN THINGS LIKE LEUKEMIA. SO 90% OF KIDS WITH LEUKEMIA NOW GET CURED. AND THE STRIDES WE HAVE MADE IN HEART DISEASE AND AIDS AND STROKE. AND THEN IF YOU LOOK AT SUICIDE, IT'S COMPLETELY FLAT. SO WE HAVE NOT BEEN ABLE TO MAKE A DENT IN THIS SUICIDE RATE YET. LOOKING AT THE MOST RECENT CDC STATISTICS, WHICH CAME OUT FOR 2016, IT IS STILL THE SECOND-LEADING CAUSE FOR DEATH FOR YOUTH 10-24 YEARS. OVER 6100 KIDS KILL THEMSELVES IN 2016 AND THIS GRAPH JUST KEEP GOING UP-AND-UP. AND IN FACT, THERE IS MORE DEATHS FROM SUICIDE THAN THESE SEVEN OTHER LEADING MEDICAL CAUSES COMBINED. SO IF WE LOOK BY STATE, YOU CAN SEE THAT ALASKA AND MONTANA HAVE HIGHER RATES THAN PLACES LIKE NEW JERSEY AND CONNECTICUT BUT LOOK AT THAT RANGE. THESE ARE DEATHS PER 100,000 BUT THE RANGE IS JUST STAGGERING. YOU CAN GO FROM 4.INATE NEW JERSEY TO 34 PER 100,000 IN ALASKA. MARYLAND HAPPENS TO HAVE THE FIFTH LOWEST RATE NATIONALLY. BUT EVEN ONE DEATH FROM SUICIDE IS TOO MUCH. SO LOCALLY, WE HAVE SEEN THIS JUST A COUPLE MONTHS AGO HERE IN THIS AREA. THERE WAS TWO TEENAGERS THAT KILLED THEMSELVES FROM TWO LOCAL HIGH SCHOOLS WITHIN ONE WEEK. SO REALLY JUST A STAGGERING PUBLIC HEALTH PROBLEM. SO SUICIDE STILL RELATIVELY RARE. WHAT IS MORE COMMON THAN SUICIDE IS SUICIDAL BEHAVIOR. ABOUT TWO MILLION ADOLESCENTS ATTEMPT SUICIDE EVERY YEAR AND TO YOUR POINT, DR. BRENT, THIS IS THE YOUTH RISK BEHAVIOR SURVEY DATA. SO MAYBE AN OVERESTIMATE. HOWEVER, SO ABOUT 9% OF YOUR AVERAGE HIGH SCHOOL STUDENTS HAS REPORTED THAT THEY ATTEMPTED SUICIDE ONE OR MORE TIMES IN THE PAST YEAR. AND EVEN MORE COMMON THAN SUICIDAL BEHAVIOR IS SUICIDAL THOUGHTS. SO IF YOU GO INTO YOUR AVERAGE HIGH SCHOOL IN THE UNITED STATES, 18% OF YOUR AVERAGE HIGH SCHOOL STUDENTS WILL REPORT THAT THEY SERIOUSLY CONSIDERED ATTEMPT KILLING THEMSELVES. AND EVEN IF THOSE KIDS AREN'T AT IMMINENT RISK, THEY CERTAINLY ARE IN SIGNIFICANT EMOTIONAL DISTRESS IF THEY ARE HAVING FREQUENT THOUGHTS OF SUICIDE. SO JUST A WORD ABOUT THE YOUNGER CHILDREN. SO CHILDREN -- THERE USED TO BE A MYTH THAT CHILDREN UNDER 12 DON'T THINK ABOUT SUICIDE. BUT THEY ACTUALLY PLAN, ATTEMPT AND DIE BY SUICIDE. AND IN FACT, IT IS NOW THE SECOND LEADING CAUSE OF DEATH FOR 10-14-YEAR-OLDS. AND IT RECENTLY JUST SURPASSED DEATH BY TRAFFIC ACCIDENTS, WHICH USED TO BE THE LEADING CAUSE OF DEATH. IT'S ALSO THE TENTH LEADING CAUSE OF DEATH FROM CHILDREN 5-11. SO MY COLLEAGUE, DR. JEFF BRIDGE FROM NATIONWIDE CHILDRENS IS A CO-CREATOR OF THE ASK, A SCREENING TOOL I WILL TELL YOU ABOUT, BUT I WAS FORTUNATE ENOUGH TO BE INCLUDED IN THIS STUDY HE DID LOOKING AT THE RATES FOR CHILDREN UNDER 12. WHAT WE FOUND WAS THAT IT LOOKED PRETTY STABLE, THE SUICIDE RATE. HOWEVER, IF YOU PARSED IT OUT BY RACE, THERE WAS A SIGNIFICANT RACIA DISPARITY WITH THE RACE INCREASING FOR BLACK CHILDREN AND DECREASING FOR WHITE CHILDREN. IN ADDITION, WHAT WAS REALLY INTERESTING ABOUT THIS STUDY WAS 30% OF THE KIDS THAT DIED BY SUICIDE, THIS WAS LOOKING AT A DEATH REGISTRY. THESE ARE KIDS THAT DIED BY SUICIDE. 30% DISCLOSED THEIR THOUGHTS OF SUICIDE TO AN ADULT BEFORE THEIR DEATH. SO THIS CREATES OPPORTUNITY FOR CAPTURE. SO WHAT MAKES KIDS SO HARD TO -- TO DETECT SUICIDE RISK? FIRST OF ALL, THEY ARE SECRETIVE. SO 85% -- THIS IS A STUDY OF SUICIDE ATTEMPTERS AND IDEATORS FROM AN EMERGENCY DEPARTMENT. WHAT WE FOUND -- NOT WE BUT WHAT THE NEGRON FOUND WAS THAT 85% DID NOT REVEAL THEIR SUICIDE IDEATION TO ANYONE. AND 30-60% DIDN'T TELL ANYONE THEY HAD TRIED TO KILL THEMSELVES BEFORE. AND THIS STATISTIC WAS REALLY STAGGERING. 90% OF SUICIDE ATTEMPTS WENT UNKNOWN TO THE PARENTS. AND WHEN PARENTS TELL YOU, I DIDN'T KNOW, THAT'S BECAUSE MOST OF THEM DO NOT KNOW THAT THEIR KIDS ARE THINKING ABOUT IT AND TRYING TO KILL THEMSELVES. AND THEN THE MOST FRIGHTENING STATISTIC THAT COMES OUT OF THIS STUDY IS 69% OF THE KIDS IN THE STUDY REPORTED THAT THEY HAD LESS THAN A 30 OF HAD MINUTE INTERVAL BETWEEN THINKING ABOUT IT AND EXECUTING IT. SO, THIS IS WHY EARLY DETECTION IS SO CRITICAL BECAUSE IF YOU CAN GET IN FRONT OF THIS, AND THEN COME UP WITH COPING STRATEGIES, THEN YOU POSSIBLY CAN PREVENT SUICIDE. SO JUST TALK BRIEFLY ABOUT THE RISK FACTOR FOR SUICIDE AND I'M NOT GOING TO GO THROUGH EVERY ONE BUT I HIGHLIGHTED PREVIOUS ATTEMPT BECAUSE THAT'S THE MOST POTENT RISK FACTOR. SOMEONE WHO HAS DONE IT BEFORE S MORE LIKELY TO DO IT AGAIN. THERE IS A SAYING IN PSYCHOLOGY THE BEST PREDICTOR OF FUTURE BEHAVIOR IS PAST BEHAVIOR AND THIS IS TRUE FOR SUICIDE. MENTAL ILLNESS, AND DR. BRENT TOUCHED ON THAT. DRUG OR ALCOHOL USE. AND THEN I HIGHLIGHTED MEDICAL ILLNESS BECAUSE THIS IS OFTEN A RISK FACTOR THAT IS OVERLOOKED BUT IMPORTANT. AND THIS IS THE ONE THAT WE ARE GOING TO FOCUS ON HERE, THE MEDICAL SETTING. MOST PEOPLE WHO HAVE THESE RISK FACTORS WILL NOT GO ON TO KILL THEMSELVES. I WILL TELL YOU THAT. BECAUSE THEY ARE RISK FACTORS. AND I'M GOING TO MAKE A MEDICAL ANALOGY HERE. IF YOU PICTURE YOURSELF AS A TRIAGE NURSE IN AN EMERGENCY DEPARTMENT, AND SOMEBODY WALKED IN WITH THE RISK FACTOR FOR HAVING A HEART ATTACK, LET'S SAY THEY WERE OBESE AND A SMOKER AND HAD HIGH BLOOD PRESSURE AND A FAMILY HISTORY, IF THEY WALKED IN AND SAW YOU AT TRIAGE, YOU WOULDN'T THINK THEY ARE HAVING A HEART ATTACK EVEN THOUGH THEY HAVE THESE RISK FACTORS. BUT IF THEY CAME IN CLUTCHING THEIR CHEST IN PAIN AND SWEATING PROFUSELY AND PAIN RADIATING DOWN THEIR LEFT ARM, YOU MIGHT THINK THEY ARE HAVING A HEART ATTACK BECAUSE THAT'S A WARNING SIGN. THE SAME THING GOES FOR SUICIDE. WE HAVE WARNING SIGNS THAT MEANS THAT SOMEONE MIGHT BE AT IMMINENT RISK. THINGS LIKE WANTING TO DIE OR TALKING ABOUT KILLING THEMSELVES OR LOOKING FOR A WAY TO KILL ONE'S SELF OR FEELING HOPELESS OR TRAPPED OR LIKE A BURDEN OR SOME OF THE SYMPTOMS DEPRESSION, SLEEPING TOO LITTLE, WITHDRAWING OR FEELING ISOLATED OR DISPLAYING EXTREME MOOD SWINGS. SO THESE ARE ALL WARNING SIGNS THAT SOMEONE MIGHT BE AT IMMINENT RISK FOR SUICIDE. SO THIS IS MY DOG, WALLY. AND I'M USING WALLY HERE BECAUSE I THOUGHT, I'M GIVING YOU SOME SOBERING STATISTICS AND SOME SOBERING FACTS AND MAYBE WE'LL TAKE A PAUSE HERE FOR A MINUTE. BECAUSE THIS IS REALLY HEAVY AND REALLY SERIOUS AND REALLY TRAGIC. BUT THERE IS A LOT OF HOPE TOO. AND SO, WE CAN ASK OURSELVES, CAN WE SAVE LIVES BY SCREENING FOR SUICIDE RISK IN THE MEDICAL SETTING? AND SO, IT'S THE BELIEF OF OUR RESEARCH TEAM THAT YES, YES, WE CAN. SO LET'S JUST TALK A LITTLE BIT ABOUT SUICIDE RISK IN THE MEDICAL SETTING. SO IF YOU LOOK AT SUICIDE IN HOSPITALS, HOSPITALS SUICIDE ARE RARE BUT THEY ARE DEVASTATING. IT'S ACTUALLY RANKED AS THE TOP -- ONE OF THE TOP 5 MOST FREQUENTLY REPORTED SENTINEL EVENTS TO THE JOINT COMMISSION. NOW THE JOINT COMMISSION IS AN ACCREDITATION BOARD THAT ACCREDITS ALL THE HOSPITALS IN THE COUNTRY. AND HOSPITALS PAY ATTENTION TO WHAT THE JOIN COMMISSION SAYS AND THEIR RULES AND REGULATIONS. THERE HAVE BEEN OVER 1300 HOSPITAL SUICIDE REPORTED IN ABOUT AN 18-YEAR PERIOD. AND THAT IS ABOUT 70 INPATIENT SUICIDE PER YEAR. AND WHAT IS STUNNING ABOUT THESE STATISTICS IS THAT MOST PEOPLE THINK, WELL, THIS OCCURS ON THE PSYCHIATRIC UNITS. BUT ACTUALLY A QUART OF THESE SUICIDE THAT HAPPEN IN HOSPITALS, OCCUR ON NON-BEHAVIORAL HEALTH UNITS. AND SO IN 2007, THE JOINT COMMISSION CREATED NATIONAL PATIENT SAFETY GOAL. THEY HAVE MANY NATIONAL PATIENT SAFETY GOALS LIKE WASHING YOUR HANDS AND REDUCING INFECTION RATES. BUT THEY HAD ONE FOR SUICIDE AND THAT WAS TO SCREEN ALL BEHAVIORAL HEALTH PATIENTS FOR SUICIDE RISK. SO IT WAS REALLY FOCUSED ON BEHAVIORAL HEALTH PATIENTS. BUT THEN WHEN THEY LOOKED AT THEIR DATA AND THEY SAW WHAT WAS GOING ON, THEY ALSO HAVE NOW EXPANDED THEIR RECOMMENDATION. IT'S NOT A PATIENT SAFETY GOAL YET BUT IT'S A RECOMMENDATION, THAT ALL MEDICAL PATIENTS SHOULD BE SCREENED FOR SUICIDE RISK. AND THIS OCCURRED IN 2016. SO IF I SHOWED YOU THE TOP FIVE MOST FREQUENTLY REPORTED SENTINEL EVENTS -- AND THE SENTINEL EVENT IS WHEN A PATIENT DIES UNEXPECTEDLY. WHAT WOULD YOU SAY? I'M GOING TOY SHOULD YOU THE TOP 5. WHAT DO YOU THINK THE FIRST ONE IS? ANYBODY WANT TO TAKE A GUESS? WHAT DO YOU THINK THE MOST FREQUENTLY-REPORTED REASON IS FOR AN UNEXPECTED DEATH IN A HOSPITAL? UNINTENDED RETENTION OF A FOREIGN BODY. SO LEAVING GAUZE IN SURGERY PATIENTS. BUT I PUT UP THE FIRST 5 TOY SHOULD YOU THAT SUICIDE IS THE THIRD AND IT'S AHEAD OF FALLS RISK WHICH IS THE FOURTH. AND WE ALL KNOW THAT HOSPITALS HAVE WAYS OF SCREENING FOR FALLS, BUT DON'T HAVE WAYS FOR SCREENING FOR SUICIDE. AND WHEN YOU DO ROOT CAUSE ANALYSIS OF THESE SUICIDE, OF THESE SENTINEL EVENTS, SUICIDES, YOU FIND THERE ARE MANY FACTORS BUT THE NUMBER 1 ROOT CAUSE IS LACK OF ACCESSMENT. SO UNDER DETECTION IS INCREDIBLE PROBLEM. IF YOU LOOK AT DEATH REGISTRY STUDIES, THE MAJORITY OF PEOPLE WHO DIE BY SUICIDE HAVE VISITED A HEALTH CARE PROVIDER MONTHS BEFORE THEIR DEATH. AND THIS IS TRUE FOR ADOLESCENTS TOO. 80% OF ADOLESCENTS WHO DIED BY SUICIDE HAD VISITED A HEALTH CARE PROVIDER. THE PROBLEM IS THESE KIDS DON'T LOOK AT THEIR DOCTORS AND SAY, DR., I WANT TO DIE. THEY FREQUENTLY PRESENT WITH SOMATIC COMPLAINTS. AND IF THEY ARE NOT ASKED DIRECTLY, ARE YOU THINKING OF KILLING YOURSELF, THEY ARE MOST LIKELY NOT GOING TO TELL ANYBODY. AND SO, THE MAJORITY OF MEDICAL SETTINGS DON'T SCREEN FOR SUICIDE RISK AND THE MAJORITY OF SUICIDE ATTEMPTERS GO UNRECOGNIZED. SO THIS IS ONE OF MY FAVORITE NEW YORKER CARTOONS. IT'S AN ELEPHANT IN PSYCHOANALYSIS. I'M RIGHT THERE IN THE ROOM AND NO ONE EVEN ACKNOWLEDGES ME. SO WE BELIEVE THAT SUICIDE RISK IS THE ELEPHANT IN THE ROOM IN A MEDICAL APPOINTMENT. SO I'M GOING TO PAUSE HERE AND I WANT TO SHOW YOU THIS PUBLIC SERVICE ANNOUNCEMENT. THIS IS A WONDERFUL PUBLIC SERVICE ANNOUNCEMENT THAT I SHOW TO ALL PARENTS THAT I COULD FIND, ACTUALLY. IT'S A MAYO CLINIC PUBLIC SERVICE ANNOUNCEMENT. THEY GAVE ME PERMISSION TO USE IT BUT IT'S -- ANYBODY CAN FIND IT ON YouTube AND I'M GOING TO STAND BACK FOR A MINUTE AND LET THESE KIDS TALK TO YOU. [ MUSIC PLAYING ] >> I HAVE MY UPS AND DOWNS JUST LIKE ANYBODY ELSE. >> MAYBE MORE THAN ANYBODY ELSE. >> I CAN BE HARD TO FIGURE OUT. >> AND I LIKE MY PRIVACY. >> I DON'T WANT YOU LOOKING OVER MY SHOULDER ALL THE TIME. >> BUT YOU KNOW YOUR KID BETTER THAN ANYBODY ELSE AND IF YOU THINK HE IS ACTING DIFFERENT THAN USUAL. >> ACTING REALLY DOWN, CRYING ALL THE TOWN FOR NO GOOD REASON ON. >> OR GETTING MAD. >> NOT ABLE TO SLEEP OR SLEEPING TOO MUCH. >> UT SHOULDING FRIENDS OUT OR GIVING STUFF AWAY. >> ACTING RECKLESS, DRUNKING, USING DRUGS. STAYING OUT LATE. >> NOT DOING STUFF HE USED TO LOVE. >> OR STUFF THAT IS NOT LIKE HIM. >> IT MIGHT BE NOTHING TO WORRY ABOUT. IT MIGHT BE JUST HIGH SCHOOL. >> OR IT MIGHT BE SOMETHING MORE. HE MIGHT BE DEPRESSED. >> NOT JUST FEELING DOWN, REALLY DEPRESSED. >> IT MIGHT BE THAT YOUR KID IS THINKING ABOUT KILLING HIMSELF. IT HAPPENS MORE THAN YOU THINK. MORE THAN IT SHOULD. >> AND PEOPLE SAY I HAD NO IDEA. >> I THOUGHT IT WAS JUST A PHASE HE WAS GOING THROUGH. >> I NEVER THOUGHT SHE WOULD DO IT. >> I WISH HE'D COME TO ME. >> I WISH I HAD SAID SOMETHING. >> THEN IT'S TOO LATE. >> SO IF YOU THINK YOUR KID IS ACTING DIFFERENT. IF SHE SEEMS LIKE A DIFFERENT PUNISH, SAY SOMETHING. >> SAY WHAT IS WRONG? HOW CAN I HELP? >> AND ASK STRAIGHT OUT. ARE YOU THINKING ABOUT KILLING YOURSELF? >> IT DOESN'T HURT TO ASK. IT HELPS. >> WHEN PEOPLE ARE THINKING ABOUT KILLING THEMSELVES, THEY WANT SOMEBODY TO ASK. >> THEY WANT SOMEBODY TO CARE. >> MAYBE YOU'RE AFRAID YOU WILL MAKE IT WARS IF YOU ASK. LIKE YOU'LL PUT THE IDEA IN THEIR HEAD. >> IT DOESN'T WORK THAT WAY. >> IT DOESN'T HURT TO ASK. THE BEST WAY TO KEEP A TEENAGER FROM KILLING HERSELF IS TO ASK. ARE YOU THINKING ABOUT TILLING YOURSELF? >> AND WHAT IF THEY SAY YES? >> OR MAYBE? >> OR SOMETIMES. >> HERE IS WHAT YOU DON'T SAY. >> THAT'S CRAZY. >> DON'T BE SUCH A DRAMA QUEEN. >> YOU'RE MAKING TOO MUCH OF IS THIS. >> THAT BOY IS NOT WORTH KILLING YOURSELF OVER. >> THAT'S NOT GOING TO SOLVE ANYTHING. >> YOU'RE JUST TRYING TO GET ATTENTION. >> YOU'RE NOT GOING TO KILL YOURSELF. WHAT YOU DO SAY IS -- >> I'M SORRY YOU'RE FEELING SO BAD. >> HOW CAN I HELP? >> WE'LL GET THROUGH THIS TOGETHER. >> LET'S KEEP YOU SAFE. >> A LOT OF PEOPLE THINKING ABOUT KILLING THEMSELVES. DEPARTMENTS AND KIDS. MOST OF THEM NEVER TRY IT. -- ADULTS AND KIDS BUT SOME DO. SO IF YOUR KID SAYS -- >> I WOULD BE BETTER OFF DEAD. >> I CAN'T LIVE WITH THIS. >> I'M GOING TO KILL MYSELF. >> TIKE HER SERIOUSLY. FIND SOMEONE TO TALK TO ABOUT IT. SOMEONE WHO KNOWS HOW TO HELP. >> A PRETTY POWERFUL -- SO FIND SOMEONE WHO KNOWS HOW TO HELP. THAT IS HOW THE MEDICAL SETTING CAN BE A BRIDGE TO MENTAL HEALTH CARE. SO WHAT ARE THE QUESTIONS THAT YOU CAN USE TO ASK KIDS AND ASSESS MEDICAL PATIENTS FOR SUICIDE RISK IN THE MEDICAL SETTING? SO BEFORE I GET INTO THAT, I JUST WANT TO TALK BRIEFLY ABOUT THE DIFFERENCE BETWEEN A SCREENING AND ASSESSMENT. SO A SCREENING IS REALLY A WAY TO IDENTIFY SOMEBODY AT RISK. IT SHOULD BE A RAPID WAY TO FLAG SOMEBODY WHO NEEDS FURTHER ASSESSMENT. THE ASSESSMENT IS A MORE COMPREHENSIVE EVALUATION AND THAT CONFIRMS THE RISK AND THEN GUIDES THE NEXT STEP. SO WHEN WE ARE TALKING ABOUT A SCREENING TOOL, WE ARE NOT TALKING ABOUT A FULL ASSESSMENT. IT IS GOING TO CAPTURE KIDS WHO MIGHT NOT BE AT IMMINENT RISK OF SUICIDE BECAUSE IT IS JUST FLAGGING SOMEBODY WHO NEEDS TO BE FURTHER ASSESSED. SO, BEFORE I GET TO THE STUDY, I WANT TO TELL YOU A LITTLE BIT ABOUT HOW WE DEVELOP THE ASK. SO I WAS WORKING UP AT BOSTON CHILDREN'S HOSPITAL IN THE LATE 90s AND AT THAT TIME, MENTAL HEALTH PATIENTS WERE FLOODING EMERGENCY DEPARTMENTS ALL OVER THE COUNTRY. AND IN FACT IT WAS THE FIRST TIME IN THE LATE 90s THAT THE SURGEON GENERAL DECLARED A MENTAL HEALTH PROBLEM AS A PUBLIC HEALTH THREAT AS DR. DAVID SATCHER DECLARED SUICIDE AS A PUBLIC HEALTH THREAT. AND IN BOSTON CHILDRENS, A 25-BED UNIT IN THE EMERGENCY DEPARTMENT. ANY GIVEN NIGHT THERE COULD BE 10 MENTAL HEALTH PATIENTS IN THOSE 25 BEDS. AND THE NURSES JUST WERE BESIDES THEMSELVES. AND THEN ONE NIGHT, ONE OF THE PSYCHIATRIC PATIENTS TOOK A MEDICAL IMPLEMENT AND STABBED THEMSELVES. AND THEN UNFORTUNATELY, THAT IS WHAT USUALLY CAUSES HOSPITALS TO PUT IN PREVENTIVE MEASURES. AND THAT IS WHEN WE DECIDED WE NEEDED A SCREENING TOOL. AND SO I WORKED WITH A GROUP OF PEOPLE AND WE CREATED THE RISK OF SUICIDE QUESTIONNAIRE. IT WAS A STUDY THAT USED MENTAL HEALTH PATIENTS ONLY AND THE SCREENING TOOL WAS FOR MENTAL HEALTH PATIENTS. WHEN I CAME DOWN TO NIH ABOUT 11 YEARS AGO, AND I WAS WORKING WITH DR. MARYLAND POW AND SHE JUST COME FROM BEING DIRECTOR OF PSYCHIATRY AT CHILDREN'S NATIONAL IN THE EMERGENCY DEPARTMENT. AND SHE SAID, CAN WE USE -- SHE WAS WORRIED ABOUT A CONSULT SUICIDALITY IN THE MEDICAL PATIENTS AND SHE SAID, CAN WE USE YOUR TOOL ON THE MEDICAL PATIENTS? I SAID, I DON'T KNOW. IT WASN'T TESTED ON THE MEDICAL PATIENTS. AND SO, SHE THOUGHT WE SHOULD LAUNCH THIS STUDY AND LET'S TEST IT OUT. AND SO, WHAT WE DID WAS DR. PAO AND DR. BALLARD WAS ALL PART OF THIS. WE CREATED THE ASK SUICIDE SCREENING QUESTION STUDY. IT INVOLVED THREE PEDIATRIC EDs, BETH WARD LED IT IN BOSTON. DR. JEFF BRIDGE LED IT AT NATIONWIDE CHILDREN'S AND WE MANNED THE CHILDREN'S NATIONAL SITE. WE HAD 524 PATIENTS ENROLLED IN THE STUDY. WE OVERSAMPLED THE MEDICAL PATIENTS BUT WE INFUSED THE SAMPLE WITH PSYCHIATRIC PATIENTS BECAUSE WE DIDN'T KNOW WHAT WE WERE GOING TO FIND AND WE WANTED TO MAKE SURE THERE WERE SUICIDAL KIDS IN THE STUDY. SO HOW DO YOU DO AN INSTRUMENT STUDY? BASICALLY, YOU TAKE A BUNCH OF CANDIDATE ITEMS AND WE TOOK 17 CANDIDATE ITEMS, AND THEY WERE ITEMS LIKE HAVE YOU EVER FELT HOPELESS LIKE THINGS WOULD NEVER GET BETTER? DO YOU FEEL LIKE YOU MIGHT GIVE UP BECAUSE YOU CAN'T MAKE THINGS BETTER FOR YOURSELF? WE COMPARED THEM -- GAVE A BUNCH OF ITEMS TO THE SUBJECTS AND THEN GAVE A GOLD STANDARD CALLED, THE SUICIDAL IDEATION QUESTIONNAIRE. NOW PEOPLE STOP ME HERE AND THEY SAY WAIT, IF YOU HAVE A GOLD STANDARD SUICIDE ASSESSMENT, WHY DO YOU NEED TO CREATE ANOTHER SCREENING TOOL IT'S BECAUSE THE SIQ30 ITEMS LONG. IT'S CUMBERSOME TO SCORE AND YOU HAVE TO BE A MENTAL HEALTH CLINICIAN TO ADMINISTER IT. NO WAY A TRIAGE NURSE WILL GIVE 30 ITEMS TO SCREEN. SO THE IDEA WAS WE WOULD CREATE OR USE THE FEWEST NUMBER OF CANDIDATE ITEMS THAT WOULD CAPTURE THE SAME KIDS AS THE GOLD STANDARD. AND SO WITHOUT GETTING TOO DEEP INTO THIS, WE LOOKED AT THE PSYCHOMETRICS OF SENSITIVITY, SPECIFICITY, AREA UNDER THE ROC CURVE, AND WHAT WE CAME UP WITH WAS THE ASK. IT HAD SENSITIVITY IS TRUE POSITIVE RATE WAS 96% AND THE SPECIFICITY WHICH IS THE TRUE NEGATIVE RATE, WE WERE VERY THRILLED TO SEE THAT IT WAS WELL 87%. SO THERE WOULD BE A LIMITED NUMBER OF FALSE-POSITIVES. AND THE QUESTIONS ARE, IN THE PAST FEW WEEKS, HAVE YOU WISHED YOU WERE DEAD? IF YOU FELT THAT YOU OR YOUR FAMILY WOULD BE BETTER OFF IF YOU WERE DEAD? IF YOU BEEN HAVING THOUGHTS ABOUT TRYING TO KILL YOURSELF? IF YOU ANSWERED YES TO ANY ONE OF THOSE FOUR QUESTIONS YOU'RE ASKED AN ACUTEY QUESTION. WHICH IS, ARE YOU HAVING THOUGHTS OF KILLING YOURSELF RIGHT NOW? ANYBODY WHO ANSWERS YES TO THAT FIFTH QUESTION IS CONSIDERED AT ACUTE RISK FOR SUICIDE AND THEY NEED SAFETY PRECAUTIONS IN THE ED. ANYONE WHO ANSWERS YES TO ONE OF THE FOUR BUT NO TO THE FIFTH IS CONSIDERED A NON-ACUTE. SO THE RESULTS OF THIS STUDY 18.7% OF THE SUBJECTS SCREENED POSITIVE BUT WE WERE MOST INTERESTED IN THE MEDICAL SURGICAL PATIENTS AND 4% OF THEM SCREENED POSITIVE WHICH WE FELT LIKE WAS A NUMBER THAT WAS HIGH ENOUGH TO WARRANT SCREENING BUT LOW ENOUGH NOT TO OVERBURDEN A BUSY ED. SO IT TOOK LESS THAN TWO MINUTES TO ADMINISTER THE QUESTIONS. IT WAS NON DISRUPTIVE TO WORK FLOW AND ACCEPTABLE. PEOPLE WERE WORRIED, PARENTS OF KIDS WHO BROKE AN ANKLE WILL NEVER LET YOU ASK THEIR KIDS ABOUT SUICIDE. IT WASN'T YOU TOO. THERE WAS A GREATER THAN 60% RESPONSE RATE FROM THE PARENTS. AND WE ASKED THE KIDS, DO YOU THINK IT'S A GOOD IDEA FOR NURSES IN EMERGENCY DEPARTMENT TO ASK KIDS ABOUT SUICIDE? AND 95% WERE IN FAVOR. SO THE ASK IS NOW AVAILABLE IN THE PUBLIC DOMAIN. JUST TOY SHOULD YOU WHAT THE KIDS SAID ABOUT ASKING ABOUT SUICIDE. THE ONES IN FAVOR SAID BECAUSE A LOT OF KIDS, ESPECIALLY TEENS GET SAD AND DON'T HAVE ANYONE TO TALK ABOUT IT WITH. SO IF A KID ISN'T ALREADY IN THE E ARE. WITH PEOPLE WHO ARE TRAINED, IT'S A GOOD TIME TO TALK BECAUSE A LOT OF THEM ARE DYING, RUNNING AWAY STRESSED OUT WITH THEIR PARENTS AND DON'T KNOW WHAT TO DO. BECAUSE SOMETIMES WHEN NO ONE ASKS THEM, THEY FEEL NO ONE CARES. AND THEN WE LOOKED AT THE NEGATIVE RESPONSES AS WELL. AND THOSE KIDS SAID THINGS LIKE YOU SHOULD ONLY ASK KIDS THAT HAVE MENTAL HEALTH PROBLEMS. BECAUSE IT'S NOT SOMETHING YOU SHOULD ASK BECAUSE IT WILL MAKE KIDS THINK ABOUT SUICIDE. SO THERE IS THAT FEAR OF RISK. AND NOT EVERYONE FEELS COMFORTABLE TELLING PEOPLE ABOUT THEIR PROBLEMS AND SOMETIMES THEY CAN LIE. SO TRYING TO BE SITE SPECIFIC, WE HAVE WRAPPED UP TWO STUDIES THAT WERE TESTING THE ASK ON THE INPATIENT MEDICAL SURGICAL UNIT AND THE OUTPATIENT PRIMARY CARE SPECIALTY CLINICS AND IT IS LOOKING LIKE IT HAS VERY HIGH SENSITIVITY AND REALLY GOOD SPECIFICITY. AND WE ARE ALSO LOOKING AT THE SCHOOL NURSE SETTING, THE ASK HAS BEEN TRANSLATED INTO THESE NINE LANGUAGES. IT IS AVAILABLE FOR ANYBODY TO USE. SO I WANTED TO JUST SAY A WORD NOW THAT THE JOINT COMMISSION IS RECOMMENDING THAT MEDICAL SETTINGS SCREEN FOR SUICIDE RISK, A LOT OF THEM ARE USING DEPRESSION SCREENS TO SCREEN. AND SO, IN OUR INPATIENT STUDY AND OUR OUTPATIENT STUDIES, WE HAVE INCLUDED A DEPRESSION SCREEN SO THAT WE CAN LOOK AT WHAT IS THE DIFFERENCE BETWEEN SCREENING FOR SUICIDE RISK AND SCREENING FOR DEPRESSION? SO WHAT WE USED WAS THE PATIENT HEALTH QUESTIONNAIRE. THE PHQ-A. IT'S A 9-ITEM DEPRESSION SCREEN AND IT IS AVAILABLE IN THE PUBLIC DOMAIN AND IT IS COMMONLY USED AND HAS A 9th ITEM THAT SAYS IN THE PAST TWO WEEKS, HAVE YOU HAD THOUGHTS THAT YOU WOULD BE BETTER OFF DEAD OR OF HURTING YOURSELF IN SOME WAY? SO, THIS QUESTION IS A LITTLE TRICKY BECAUSE IT HAS AN OR IN IT. WHEN SOMEONE RESPONDS POSITIVELY, YOU'RE NOT SURE WHICH SIDE THEY ARE ON FOR THAT. AND THE PHQ IS A WONDERFUL DEPRESSION SCREEN. SO I WILL SAY THAT. HOW DOES IT DO IN PICKING UP SUICIDE RISK? BECAUSE NOT EVERYBODY WHOSE AT RISK FOR SUICIDE IS DEPRESSED. SO WE LOOKED AT THIS AND THIS IS FROM OUR INPATIENT STUDY AT BOSTON CHILDREN'S AND CHILDREN'S NATIONAL. AND WE HAD OUT OF THE 400 PATIENTS, WE HAD 15% SCREEN POSITIVE FOR SUICIDE RISK. AND THEN WE HAD 23% SCREEN POSITIVE ON THE PHQ-A. AND THEN 9% SCREENED POSITIVE ON THAT 9th ITEM. IF YOU PUT THESE ALL TOGETHER, YOU SEE THAT IF YOU HAD ONLY SCREENED FOR DEPRESSION, WE WOULD HAVE MISSED 16 OR ALMOST 28% OF THE KIDS AT RISK FOR SUICIDE. AND SO SCREENING FOR DEPRESSION MIGHT NOT BE ADEQUATE ENOUGH TO CAPTURE PATIENTS AT RISK FOR SUICIDE. SO THAT SCREENING AND THAT IS REALLY JUST TIP OF THE ICEBERG. AND THE TITLE OF MY TALK IS HOW DO WE TURN RESEARCH INTO CLINICAL PRACTICE? SO, IN ORDER TO IMPLEMENT SCREENING, I WANTED TO START IN PRIMARY CARE AND I WANTED A PEDIATRICIAN THAT WAS A SUPER HERO. AND I WAS LUCKY. I GOT ONE. AND SO AFTER I GAVE ONE OF MY TALKS, I HAD DR. TED ABERNATHY FROM RICHMOND, VIRGINIA, GIVE ME A CALL. I WAS GIVING A TALK AT THE AMERICAN ACADEMY OF PEDIATRICS. AND HE SAID TO ME, I WANT TO IMPLEMENT SCREENING IN MY PRACTICE. CAN YOU HELP ME? AND SO, WE DECIDED THAT WE WOULD OBSERVE HIS SCREENING PROCESS AND THAT WE COULD LEARN FROM THAT ALSO. SO THERE IS DR. ABERNATHY AND HIS BRAVE CREW THAT SCREENED, IMPLEMENTED SUICIDE RISK. SO ONE OF HIS MAIN CONCERNS HE THOUGHT THE PARENTS WOULD HAVE IS A COMMON CONCERN ABOUT, CAN ASKING KIDS QUESTIONS ABOUT SUICIDE PUT THE IDEA IN THEIR HEADS? AND SO, WE MADE SURE TO GET IN FRONT OF THAT CONCERN BECAUSE THAT IS ONE OF THE BIGGEST THINGS PARENTS WORRY ABOUT. SO, WE IMPLEMENTED ROUTINE SCREENING DURING HIS WELL VISITS. WE STARTED WITH WELL VISITS. KIDS 12 AND OVER. THE RECEPTION IS HANDS IN AND FOE SHEET TO THE PARENT WHEN THEY CHECK IN AND IT HIGHLIGHTS THE NURSE WILL PULL YOUR KID ASIDE AND DO VITALS AND ASK YOUR CHILD ABOUT SUICIDAL. THIS IS SAFE AND IT IS IT NOT PUT IDEAS INTO THEIR HEAD. WE TIRED TO STEP IN FRONT OF THAT. THE ASK WAS ADMINISTERED BY THE NURSE DURING THE INITIAL NURSING ASSESSMENTMENT. IT WAS SCORED IN REALTIME AND THEN ANYONE WHO SCREENED POSITIVE THE PHYSICIAN WAS NOTIFIED. SO WHAT DID WE FIND? I'LL JUST TELL YOU I COULDN'T PUT UP THE RESULTS YET BECAUSE IT'S UNPUBLISHED DATA AND SO I'LL JUST TELL YOU THAT WHAT WE FOUND IN DR. ABER NATH'S'S STUDY IN ABOUT NINE MONTHS, WE LOOKED AT 270 PATIENTS AND HE HAD A 12% SCREEN POSITIVE RATE. AND WHILE 12% SOUNDS HIGH, IT REALLY AMOUNTED TO MAYBE ABOUT ONE EXTRA PATIENT PER WEEK: WHAT WAS REALLY IMPORTANT TO HIM AND HIS TEAM WAS THAT ABOUT 18 OF THOSE PATIENTS -- SO THERE ARE 32 PATIENTS THAT SCREENED POSITIVE FOR SUICIDE RISK. 18 OF THEM HAD SCREENED POSITIVE BECAUSE THEY CHECKED YES TO, I HAD TRIED TO KILL MYSELF IN THE PAST. SO THESE WERE SUICIDE ATTEMPTS THAT THE PEDIATRICIANS DIDN'T KNOW ABOUT THAT THEY NOW KNOW ABOUT. WHAT IS ALSO INTERESTING ABOUT THAT, AND WE ARE FINDING THAT NOW IN ALL OF OUR STUDIES, IS THAT HALF OF THE POSITIVE SCREENS ARE A SINGLE YES TO THE, HAVE YOU EVER TRIED TO KILL YOURSELF IN THE PAST. AND WHAT THAT MEANS IS THAT IT MIGHT NOT BE SOMETHING THE PEDIATRICIAN HAS TO DEAL WITH IN THAT VISIT BECAUSE IT IS SOMETHING THE PARENT ALREADY KNOWS ABOUT. IT IS SOMETHING, MAYBE THE CHILD IS IN MENTAL HEALTH CARE. AND SO MAYBE HALF OF THOSE POSITIVE SCREENS ARE NOT SOMETHING YOU HAVE TO DEAL AT THE WELL VISIT. WE ALSO ASKED THE KIDS, WHAT DO YOU THINK ABOUT BEING ASKED? AND 98% WERE IN FAVOR. AND AGAIN, THESE WERE THE SAME THEMES THAT WE SAW IN THE EMERGENCY ROOM. IT HELPS TO HAVE SOMEONE ASK. THEY ARE MORE COMFORTABLE TALKING TO A DOCTOR THAN THEY ARE TO THEIR PARENTS SOMETIMES. FEELING THAT SOMEONE CARES. AND THEY REALLY THINK THAT MENTAL HEALTH IS IMPORTANT. AND THEN THE COMMON THEMES AGAINST SCREENING WERE THINGS LIKE, IT'S NOT THE APPROPRIATE SETTING AND THE FEAR THAT THEIR PARENTS WILL FIND OUT. AND BY THE WAY, WHEN THE KID DOES SCREEN POSITIVE, THE PARENTS DO NEED TO FIND OUT AND I TALKED TO DR. ABERNATHY AND HOW HE HAS BEEN HANDLING THAT. HE TOLD ME STRAIGHT OUT, HE SAID, I STAY TO THE KID, I DON'T WANT TO SEE YOU DEAD. AND SO YES, I'M GOING TO TALK TO YOUR PARENT ABOUT IT BECAUSE I TAKE THIS REALLY SERIOUSLY AND THIS IS SOMETHING THAT THE ADULTS IN YOUR LIFE NEED TO KNOW ABOUT. WHAT DO THE PARENTS THINK? THE PARENTS, THE MAJORITY WERE IN FAVOR BUT LESS THAN THE KIDS. 70% OF THE PARENTS WHO WERE ASKED SAID THEY WERE IN FAVOR OF IT. ABOUT 10% WERE NOT IN FAVOR OF IT. AND ABOUT -- THE REST WERE KIND OF AMBIVALENT ABOUT IT. THEY WEREN'T SURE. AND SO, THEIR REASONS FOR BEING IN FAVOR WERE THINGS LIKE, THEY THOUGHT THE KIDS WOULD BE MORE COMFORTABLE SHARING THIS INFORMATION WITH THE DOCTOR THAN WITH THEM. THE IMPORTANCE OF SUICIDE PREVENTION, AND THE IMPORTANCE TO NORMALIZE THE CONVERSATION. DESTIGMATIZE IT. THE COMMON THEMES AGAINST WERE THAT IT WOULD MAKE THE CHILD UNCOMFORTABLE, PUT IDEAS INTO THEIR HEAD AND IT WASN'T THE APPROPRIATE SETTING. SO WHAT IS DIFFERENT FOR PEDIATRICS IS THAT, ALWAYS, IS THAT IT'S NOT JUST YOUR PATIENT YOU'RE TREATING A PATIENT AND THE PATIENT AND THE FAMILY. AND SO, WE GIVE A FLYER TO THE PARENTS TO GIVE THEM A HEADS UP. THE PARENTS ARE ASKED TO STEP OUT OF THE ROOM WHILE THIS IS REALLY IMPORTANT, BECAUSE THE KIDS WILL BE MORE FRANK MOST LIKELY IF YOU ASK THE PARENT TO STEP OUT. YOU CAN ALSO ASK WITH THE PARENT IN IF THE PARENT REFUSES TO LEAVE, WHICH THEY DO SOMETIMES. IT'S ALSO GOOD MODELING OF HOW TO TALK TO KIDS ABOUT SUICIDE. A NO RESPONSE ON THE ASK, IF A CHILD REFUSES TO ANSWER, THAT IS TREATED LIKE A NON-ACUTE POSITIVE SCREEN BECAUSE IN DR. BRIDGE LOOKED AT HIS DATA FROM NATIONWIDE CHILDREN'S AND WHAT THEY SAW WAS ABOUT 85% OF KIDS WHO REFUSED TO ANSWER, HAD PSYCHIATRIC HISTORIES. PATIENTS UNDER 18 ARE TOLD THEIR ANSWERS WILL BE SHARED WITH THEIR PARENTS. AND JUST IN GENERAL, A LIFETIME HISTORY OF SUICIDE IDEATION OR BEHAVIOR IN KIDS IS MORE SIGNIFICANT SIMPLY BECAUSE THEY HAD LES LIFETIME YEARS TO LIVE. SO A 6-YEAR-OLD -- SO THE HOSPITAL AT NIH, THE CLINICAL CENTER WHERE WE ARE IMPLEMENTING THIS SCREENING, SOMETIMES WE GET 6-YEAR-OLDS WHO TELL US THEY TRIED TO KILL THEMSELVES WHEN THEY WERE IN THEIR 20s. THAT'S DIFFERENT THAN THE 16-YEAR-OLDS WHO TRIED TO KILL HIMSELF WHEN HE WAS 13. IT'S JUST A DIFFERENT TIMEFRAME. SO IN ORDER TO HELP PEOPLE IMPLEMENT THE ASK, WE CREATED A TOOLKIT AS A GUIDE. THERE IS A WEBSITE NOW THAT JUST HAS GONE LIVE. A SUMMARY WE HAVE BROKEN THE TOOLKIT DOWN BY VENUE SO THE EMERGENCY DEPARTMENT, INPATIENT MEDICAL SURGICAL UNITER AND OUTPATIENT PRIMARY CARE AND SPECIALTY CLINICS. WE HAVE A FLYER. WE HAVE SCRIPTS FOR NURSES SO THAT WE CAN TEACH NURSES HOW YOU INTRODUCE THIS SUBJECT. AND THEN WHAT YOU DO WHEN THE PATIENT SCREENS POSITIVE. SO WE ASK NURSES AND THE BOSTON CHILDREN'S HOSPITAL NURSES WERE REALLY INSTRUMENTAL IN HELPING US DEVELOP THIS SCRIPT. WE KIND OF FIRST CAME UP WITH THE SCRIPT WHERE WE HAD KIND OF A LONG LENGTHY MIND AND BODY ARE RELATED AND WE CARE ABOUT BOTH. AND THE NURSES THEY LOOKED AT US AND SAID CAN WE JUST CUT TO THE CHASE? CAN WE JUST SAY NATIONAL GUIDELINES SAY WE SHOULD BE ASKING ABOUT THIS AND WE ARE GOING TO ASK YOU TO STEP OUT. SO WE CHANGED THE SCRIPT. AND THEN WHEN A PATIENT SCREENS POSITIVE, WE TRY TO HAVE THEM NOT TURN TO THE CHILD AND SAY YOU'RE SUICIDAL OR TURN TO THE PARENT AND SAY YOUR CHILD IS SUICIDAL. BUT TO SAY, WE HAVE CONCERNS ABOUT YOUR SAFETY AND SOMEONE WILL COME IN WHO IS TRAINED TO TALK TO KIDS ABOUT SUICIDE. SO, ONCE THE PATIENT SCREENS POSITIVE, WE -- WHAT I TOLD YOU IN THE TAKE HOME MESSAGE IS THE MOST IMPORTANT PART IS THIS BRIEF SUICIDE SAFETY ASSESSMENT. AND THE REASON WHY THIS IS SO IMPORTANT IS BECAUSE YOU'RE GOING TO FLAG KIDS WHO MIGHT NOT NEED FURTHER MENTAL HEALTH EVALUATION. AND I HAVE SEEN HOSPITALS DO THIS WHERE A CHILD SCREENS POSITIVE AND THEN THEY ARE STRIPPED OF THEIR CLOTHES, EVERYTHING IS TAKEN AWAY AND THEY RECEIVE A 90-MINUTE MENTAL HEALTH EVALUATION. AND THERE IS NOTHING THAT SHUTS A SCREENING PROGRAM DOWN FASTER THAN THAT. AND THAT IS BECAUSE YOU NEED TO DO THIS INTERMEDIATE STEP OF THE BRIEF SUICIDE SAFETY ASSESSMENT TO DETERMINE, IS THIS SOMETHING THAT NEEDS FURTHER EVALUATION AND NEEDS IT NOW? OR IS THIS SOMETHING THAT DOESN'T? WE CREATED THE BRIEF SUICIDE SAFETY ASSESSMENT BUT YOU CAN ALSO USE THINGS LIKE THE COLUMBIA, THE CSRS IS A GOOD SECOND TIER ASSESSMENT. AND WHAT WE -- THIS IS THE ONE DEVELOPED FOR OUTPATIENT PEDIATRICIANS AND WHAT WE HOPE IS THAT IF YOU WALK THROUGH THIS WITH THE PATIENT IN ABOUT 10-15 MINUTES, YOU CAN GET TO FOUR CHOICES. CHILD NEEDS EMERGENCY PSYCHE EVALUATION SENT TO THE ED. FURTHER EVALUATION IS NECESSARY AS SOON AS POSSIBLE. THE CHILD MIGHT BENEFIT FROM A FURTHER EVALUATION BUT IT'S NOT URGENT. AND NO FURTHER EVALUATION IS NECESSARY. IN THE TOOLKIT ARE ALSO MENTAL HEALTH RESOURCES. THE CRISIS TEXT LINE, SUICIDE HOTLINE, LINKS TO VIDEOS. SO SOME OF THE LESS TOONS WE LEARNED FROM OVERSEEING IMPLEMENTATION AND HAVING SOME BIRDS EYE VIEWS AND PLACES LIKE PARK LAND AT UNIVERSITY OF TEXAS SOUTHWESTERN IMPLEMENTED SUICIDE RISK SCREENING IN 67,000 KIDS. HOSPITAL-WIDE THEY USED THE ASQ. I HAVE TO KEEP MY JAW FROM DROPPING WHEN I SAY THAT -- ON 67,000 KIDS. WHAT WE ARE LEARNING AND AT BOSTON CHILDREN'S THEY IMPLEMENTED IN EMERGENCY DEPARTMENT. WHAT WE ARE LEARNING IS INVOLVED PHYSICIAN AND NURSING LEADERSHIP RIGHT FROM THE START T REQUIRES A CLINICIAN CHAMPION TO -- YOU NEED SOMEONE WHO IS ON THE FRONT LINES, TRAIN THE NURSES, SCREENING HAS TO BE SYSTEMATIC. THEY HAVE TO LEARN TO ASK THE QUESTIONS VERBATIM AT ONE OF THE HOSPITALS WE WENT TO. WE DID A DEBRIEF WITH THE NURSES A FEW MONTHS AFTER THEY WERE SCREENING AND SOME OF THEM SAID, I CHANGED THE QUESTION SOMETIMES BECAUSE I DIDN'T REALLY LIKE THEM. AND SO WE TALK ABOUT HOW THESE ARE EMPIRICALLY DERIVED ITEMS AND YOU GOT TO ASK THEM VERBATIM. TEACH THEM HOW TO POLITELY ASK THE PARENT TO LEAVE THE ROOM. IF POSSIBLE, MAKE THE SCREENING QUESTIONS FORCED IN THE ELECTRONIC HEALTH RECORD. WE ALSO ALERT THE MDs IN THESE SYSTEMS. WE OFFER TO TRAIN THEM BUT A LOT OF TIMES THAT ISN'T POSSIBLE. POSITIVE SCREENS ARE MANAGEABLE. SO, THERE IS A LOT OF HOSPITALS THAT ARE AFRAID THAT YOU'RE GOING TO JUST DOUBLE THEIR BOARDING THAT IS ALREADY HAPPENING IN THE EMERGENCY DEPARTMENT. IT'S NOT TRUE. IT'S NOT HAPPENING. BOSTON CHILDREN'S HOSPITAL IMPLEMENTED SCREENING IN THE FALLAND THEY HAVE NOT ADDED TO THEIR BOARDING CRISIS. IT'S NON DISRUPTIVE AND THE MAJORITY OF PARENTS ARE OKAY WITH LEAVING THE ROOM. TO WRAP UP. STRATEGIES FOR REDUCING YOUTH SUICIDE. UNIVERSAL SCREENING WITH HIGH-RISK POPULATIONS. THE PUBLIC HEALTH IMPORT OF SCREENING IS IMMENS BECAUSE EVEN IF THE CHILD IS NOT AT RISK FOR IMMINENT SUICIDE, YOU CAN SOMETIMES PICK UP SERIOUS MENTAL ILLNESS, SUBSTANCE ABUSE, HOMICIDEAL IDEATION OR HISTORY OF PHYSICAL AND SEXUAL ABUSE. THE MEDICAL SETTING IS A REALLY IMPORTANT VENUE. USE POPULATION AND WILL SITE-SPECIFIC VALIDATED SCREENING INSTRUMENTS IF YOU'RE GOING TO SCREEN. IT CAN TAKE 20 SECONDS. IT REQUIRES PRACTICE GUIDELINES THAT ARE IN PLACE FOR MANAGING THE POSITIVE SCREENS. AGAIN, THIS THREE-TIERED PATHWAY, THE BRIEF SCREEN, THE 10 MINUTE BSSA AND NA DECIDES WHETHER OR NOT THE PATIENT NEEDS A FULL MENTAL HEALTH EVALUATION. AND SCREEN IS A CRITICAL STEP IN SUICIDE PREVENTION AND WE REQUIRE EFFECTIVE TREATMENTS. I'M GOING TO JUST END WITH THIS PATIENT EXAMPLE. IN DR. ABERNATHY'S GROUP THERE WAS A 18-YEAR-OLD AND HIS MOTHER FATIGUED AND SHE THOUGHT HE HAD MONO. HE WAS LAYING AROUND ALL THE TIME. AND WHAT HAPPENED WAS THE NURSES WERE ONLY SUPPOSED TO SCREEN THE WELL VISITS BUT THE NURSE JUST HAD A BAD FEELING ABOUT THIS. I CAN'T TELL YOU HOME KIDS LIVES WERE SAVED BECAUSE A NURSE HAS A BAD FEELING ABOUT SOMETHING. AND SO SHE ADMINISTERED THE ASQ. AND THIS CHILD SAID YES, ON ALL THREE OF THESE. HE HAD NEVER THOUGHT OF KILLING HIMSELF BEFORE. BUT HE WAS HAVING THOUGHTS OF KILLING HIMSELF RIGHT THEN. THIS WAS A SCHOLAR ATHLETE. WELL CONNECTED SOCIALLY. A KID NO ONE THOUGHT WAS HAVING ANY ISSUES. AND HAD THAT NURSE NOT SCREENED HIM FOR SUICIDE RISK, HE PROBABLY WOULD HAVE BEEN A SUICIDE YOU READ ABOUT IN THE PAPER THE NEXT DAY. HE HAD BEEN AT A PARTY AND IT HAD BEEN RAIDED BY THE POLICE AND HE WAS IN JEOPARDY OF LOSING HIS SCHOLARSHIP. WHEN THE DOCTOR TALKED TO HIM, HE JUST WAS BESIDES HIMSELF WITHOUT HOPE AND DR. ABERNATHY WAS BESIDES HIM WITH WHETHER HE SHOULD SEND HIM TO THE ER OR SEND HIM HOME THE AND THE TEENAGER SAID, I HAVE HOPE NOW BECAUSE YOU ASKED ME ABOUT THIS AND I TALKED ABOUT IT. SO I THINK THIS NURSE REALLY SAVED THIS KID'S LIFE. SO IF YOU GIVE ME 28 MORE SECONDS, I'M GOING SHOW YOU -- THIS IS DR. ABER NATHY AND ONE OF OUR SPEAKERS WHO WILL SPEAK TO YOU IN A LITTLE BIT. SHE INTERVIEWED HIM AND MADE THIS VIDEO AND A LOT OF TIMES WHEN I TALK TO PEDIATRICIANS THEY ARE REALLY, REALLY CONCERNED ABOUT THE POSITIVE SCREENS, HOW AM I GOING TO MANAGE THE PATIENTS THAT SCREEN POSITIVE? THIS IS WHAT DR. ABERNATHY HAS TO SAY. >> NO ONE DESERVES TO DIE BY SUICIDE. NO ONE. AND THE ONE THING THAT MOTIVATED OUR GROUP MORE THAN ANYTHING IN THE WORLD WHEN WE STARTED TALKING ABOUT DOING THIS WAS, IT WASN'T HOW MANY WERE WE GOING TO CATCH. IT WAS HOW ARE WE GOING TO DEAL WITH ONE THAT WE DON'T CATCH. AND HOW ARE WE GOING TO HANDLE THE DEATH OF ONE OF OUR PATIENTS BY SUICIDE? AND THAT WE COULDN'T LIVE WITH. >> THANK YOU VERY MUCH FOR YOUR ATTENTION. [ APPLAUSE ] >> THANK YOU VERY MUCH FOR THE EXCELLENT TALK. I WAS ABLE TO ENJOY IT FROM UP ABOVE WHERE THE VISIBILITY WAS RESTRICTED BUT I COULD LISTEN TO YOU AND SEE YOUR WONDERFUL SLIDES. WE ARE VERY FORTUNATE TO HAVE AS OUR NEXT SPEAKER, ELIZABETH BALLARD. WHO IS A STAFF CLINICIAN AT THE EXPERIMENTAL THERAPEUTICS AND FATHO PHYSIOLOGY BRANCH OF THE DIVISION OF INTRAMURAL RESEARCH AT THE NIMH. SHE IS A LICENSED CLINICAL PSYCHOLOGIST AND RECEIVED HER GRADUATE TRAINING AT CATHOLIC UNIVERSITY. DID HER PSYCHOLOGY INTERNSHIP AT THE VETERANS AFFAIRS MEDICAL CENTER IN DENVER, COLORADO. SHE COMET PLAD POSTDOCTORAL FELLOWSHIP AT JOHNS HOPKINS AND SHE IS LEADING A NUMBER OF PROJECTS HERE. YOU WILL HEAR ABOUT SOME OF THEM. THEY CENTER AROUND SUICIDE ASSESSMENT AND RAPID-ACTING TREATMENTS AND CRUCIALLY THE NEUROBIOLOGY OF SUICIDE. SHE IS NOT JUST ACADEMICALLY VERY GIFTED BUT ALSO VERY BRAVE TO BE WORKING IN THIS FIELD FOR TWO REASONS. FIRST BECAUSE IT IS OF COURSE THE TOPIC. SECONDLY BECAUSE SHE HAD TO CONVINCE A NUMBER OF PEOPLE ABOUT THE IMPORTANCE OF THE TOPIC AND ABOUT HOW TO CONDUCT A SAFE RESEARCH IN THIS AREA. SO WE WILL BE VERY PLEASED TO HEAR ABOUT YOUR RESEARCH. THANK YOU VERY MUCH. [ APPLAUSE ] FIRST I'M A LITTLE BIT SOFT SPOKEN. CAN EVERYBODY IN THE BACK HEAR ME OKAY? PLEASE LET ME KNOW THROUGHOUT IF YOU WILL STOP HE ME. SO FIRST I HAVE TO SAY A BIG THANK YOU TO DR. TOBIN AND DR. STRING STRING FOR INVITING ME. USUALLY WHEN I GIVE A TALK I HAVEN'T HAD SUCH A FANTASTIC INTRODUCTION TO THE TOPIC OF SUICIDE AND ESPECIALLY SORT OF A REALLY CLEAR GROUNDING OF THE IMPORTANCE OF IT, HOW IT IS ASSESSED. SO, WHAT I'M GOING TO BE FOCUSING ON IS A LOT OF RESEARCH THAT IS GOING ON HERE AT THE CLINICAL CENTER AT N EMR AND ONE POSSIBLE I'LL ALLUDE TO WHAT HAS ALREADY BEEN SAID. SO I DO REALIZE THAT IN MY SLIDE CREATION I'M SORRY, I HAVE TO ACKNOWLEDGE I'M A FEDERAL EMPLOYEE. I HAVE NO CONFLICTS TO DISCLOSE AND ALL THESE OPINIONS ARE MY OWN. SO WHAT I'M GOING TO BE TALKING ABOUT TODAY IS A LITTLE BIT OF THE PROMISE OF BARRIERS TO SUICIDE RESEARCH. IT'S SOMETHING THAT WE GREATLY NEED AND AT THE SAME TIME ALLUDED TO IT IS VERY DIFFICULT TO HAPPEN. I'M GOING GIVE AN INTRODUCTION TO THE NEUROBIOLOGY OF SUICIDE PROTOCOL. A PROTOCOL THAT IS ONGOING HERE AT THE NATIONAL INSTITUTES OF MENTAL HEALTH. I'M GOING TO TALK A LITTLE BIT ABOUT THE PROCESS TO ENSURE THE SAFETY OF OUR RESEARCH PARTICIPANTS AND THEN I'M GOING TO HIGHLIGHT SOME NOVEL APPROACHES TO SUICIDE RESEARCH, SPECIFICALLY TALKING ABOUT SOME SLEEP RESEARCH AND DR. BRENT ALREADY DESCRIBED THIS A LITTLE BIT, I'M GOING TO BE TALKING ABOUT SUICIDE IMPLICIT ASSOCIATION TASK AND HOW THAT RELATES TO IMAGING. SO, FIRST STARTING WITH THE PROMISE OF AND BARRIERS TO SUICIDE RESEARCH. SO, OVER ALL, I THINK EVEN THE LAST COUPLE OF YEARS, THERE HAS BEEN EXPLOSION AT LEAST IN THE NEWS MEDIA OF INTEREST IN œI'M JUST BRINGING UP THREE RECENT CASES, ONE OF THESE IS ONE OF THE PAPERS THAT DR. BRENT JUST TALKED ABOUT ABOUT HIS MACHINE LEARNINGAL GO RYTH IMIMAGING. SO MORE AND MORE FROM A NEWS MEDIA PERSPECTIVE, PEOPLE ARE INTERESTED IN SUICIDE. WHAT IS GOING ON WITH SUICIDE RESEARCH, HOW CAN WE FIND OUT MORE MORE? ARE THERE BLOOD TESTS? APPS? BRAIN IMAGING? I WANT TO ALLUDE TO THE FACT THAT I THINK MORE AND MORE PEOPLE ARE -- THE STIGMA AROUND REVEALING THAT YOU HAVE EXPERIENCED SUICIDAL THOUGHTS AND BEHAVIOR IS DECREASING. YOU SEE CELEBRITIES, ESPECIALLY YOUNG ADULT CELEBRITIES WILL COME OUT AND SAY, YES I HAVE ATTEMPTED SUICIDE OR YES, I HAVE CONSIDERED SUICIDE. YOU SEE THIS A LOT MORE ON SOCIAL MEDIA. THERE IS POSITIVE AND NEGATIVE ELEMENTS TO THAT BUT MORE AND MORE YOUNG PEOPLE ARE MORE WILLING TO DISCLOSE THIS AND ARE FREE TO TALK ABOUT IT. SO TO A CERTAIN EXTENT IT'S A VERY, VERY EXCITING TIME AND OBVIOUSLY THE FACT THAT THIS ROOM IS SO FILLED WITH PEOPLE JUST REALLY SPEAKS TO THE IMPORTANCE OF THIS TYPE OF RESEARCH. AND AT THE SAME TIME, I'M NOT GOING TO BELABOR THIS BECAUSE BOTH OF THE SPEAKERS ALLUDED TO THIS. THERE IS A GREAT TIME OF PROMISE AND AT THE SAME TIME THE SUICIDE RATES ARE GOING UP. AND AGAIN JUST REITERATING WE ARE SEEING HIGHEST INCREASES AMONG PARTICULARLY MIDDLE-AGED WOMEN AND YOUNGER GIRLS. SO WHY IS SUICIDE RESEARCH SO DIFFICULT? THIS IS THE LEADING CAUSE OF PSYCHIATRIC RELATED DEATH BUT WHY DON'T WE KNOW MORE ABOUT IT? THERE ARE A NUMBER OF ETHICAL CONCERNS FOR RECRUITING, HOW DO WE CONSENT, HOW DO WOO WE DO THE SAFETY OF ENVIRONMENT WITHIN A RESEARCH ENVIRONMENT MAKING SURE THAT WE ARE TREATING THESE PATIENTS ACCORDINGLY. FOR THE MOST PART, IN TERMS OF PSYCHIATRIC RESEARCH, USUALLY THE FIRST LINE EXCLUSION, THE FIRST GROUP OF PATIENTS THAT ARE EXCLUDED FROM A STUDY ARE THE PEOPLE THAT REPORT SUICIDAL THOUGHTS AND BEHAVIORS. ESPECIALLY IF YOU LOOK AT SOMETHING NON-SUICIDE SPECIFIC YOU LOOK AT DEPRESSION CLINICAL TRIAL AND EXCLUSION FACT EXPOSE THAT'S IT. IT'S USUALLY SUICIDE. ANYBODY AT IMMINENT RISK IS NOT STUDIED. IN FACT, THEY HAVE DONE EVALUATIONS OF ESPECIALLY DEPRESSION CLINICAL TRIALS AND IF ANYTHING, THEY HAVE GOTTEN MORE RESTRICTIVE OVER THE LAST DECADES. INDIVIDUALS, IRBs ETHICAL CONSIDERATIONS, ARE SO NERVOUS ABOUT ENROLLING THESE PATIENTS INTO STUDY THAT MORE AND MORE, THEY ARE BEING EXCLUDED FROM STUDY. HOWEVER, THEN HOW DO WE KNOW OUR TREATMENTS WORK FOR THESE INDIVIDUALS WHO REALLY, I WOULD ARGUE NEED IT THE MOST. SO I'M GOING TO ALLUDE A LITTLE BIT TO THE TREATMENTS BUT AGAIN WE HAVE ALSO ALREADY HAD A GREAT DISCUSSION ESPECIALLY ABOUT PSYCHOTHERAPY INTERVENTIONS. IN TERMS OF PHARMACOLOGICAL INTERVENTIONS FOR SUICIDAL INDIVIDUALS, THERE IS A GRAND TOTAL OF ONE FDA APPROVED MEDICATION FOR SUICIDAL BEHAVIOR. IT'S FDA APPROVED AND IT IS ONLY FOR INDIVIDUALS WITH SCHIZOPHRENIA. THERE IS A LONGSTANDING HISTORY OF THE POTENTIAL IMPROVEMENT AND TREATMENT WITH LITHIUM BUT IT IS NOT FDA APPROVED AND DOESN'T AT THIS POINT HAVE THE NUMBER OF RANDOMIZED CLINICAL TRIALS THAT ARE NEEDED FOR THAT PARTICULAR DESIGNATION. DR. BRENT ALREADY DID A GREAT SUMMARY OF THE PSYCHOTHERAPIES INCLUDING DIALECT CALL BEHAVIORAL THERAPY AND DIFFERENT FORMS OF COGNITIVE BEHAVIORAL THERAPIES. WE KNOW THESE THERAPIES ARE ASSOCIATED WITH REDUCED SUICIDE RISK. AND THERE IS ALSO THE LONGSTANDING HISTORY OF ELECTROCONVULSIVE THERAPY. HOWEVER, I JUST WANT TO HIGHLIGHT ONE THING. WE DO HAVE SOME TREATMENTS, ESPECIALLY PHARMACOLOGICALLY NOT ENOUGH. OFTENTIMES CHANGE OCCURS OVER THE LONG TERM. SO, I AM TRAINED ON DBT, WORKED HERE IN FRIENDSHIP HEIGHTS ON THIS. WE ASKED OUR PATIENTS TO BE PART OF DBT FOR AN ENTIRE YEAR. AND OFTENTIMES WE REALLY DID NEED THAT YEAR TO SEE EFFECTS. AND I THINK THEIR CBT INTERVENTIONS THAT WOULD HAPPEN OVER SHORTER TERM. A LOT OF MEDICATIONS REALLY DO TAKE WEEKS TO MONTHS TO GET EFFECTS AND EVEN MORE EMPHASIS, I DO FOCUS ON ADULTS RIGHT NOW BUT THERE ARE FEWER RESEARCH STUDIES ON WHAT WORKS FOR ADOLESCENTS. THE PROBLEM WITH THIS IS SUICIDE RISK AS WAS ALLUDED TO, HAPPENS OVER THE SHORT-TERM. THERE ARE THINGS THAT WE CAN DO FOR CHRONIC SUICIDE RISK BUT OFTENTIMES SOMEBODY COMING INTO AN EMERGENCY ROOM, IF SOMEBODY IS IN EYE PSYCHIATRIC INPATIENT UNIT, THEY NEED HELP RIGHT NOW. THEY NEED TO REDUCE THEIR SYMPTOMS RIGHT NOW. WHAT WE WE KNOW ABOUT THE CRITICAL WINDOWS IS IT'S THE WEEK AFTER PSYCHIATRIC SUBMISSION, SOMEBODY COMES TO THE EMERGENCY DEPARTMENT AND THEN IN THEIR FIRST WEEK IN THE PSYCHIATRIC INPATIENT UNIT. AND THEN THE WEEK AFTER PSYCHIATRIC DISCHARGE. UNFORTUNATELY, FROM A PHARMACOLOGICAL PERSPECTIVE, HIGHEST TIME OF SUICIDE RISK IS THE FIRST NINE DAYS AFTER STARTING AN ANTIDEPRESSANT. SO IF YOU THINK ABOUT WHAT HAPPENS AS DR. BRENT ALLUDED TO, THERE IS NOT A LOT OF PSYCHOTHERAPY THAT NECESSARILY CAN HELP ON INPATIENT UNITS. SO MAYBE YOU START SOMEBODY ON A MEDICATION AND THEN THEY ARE AT THE HIGHEST RISK TIME POTENTIALLY MEDICALLY, IS WHEN THEY ARE EXPERIENCING THIS POTENTIAL GAP IN CARE. SO I WOULD ARGUE TO YOU AND A LOT OF WHAT MY RESEARCH LONG TERM IS FOCUSING ON IS WHAT IS CRITICALLY NEEDED ARE THE NEXT GENERATION TREATMENTS, ESPECIALLY FOR THE ACTIVE SUICIDE CRISIS. AND SO WHAT I THINK WE NEED ARE THE SAFE EFFECTIVE TREATMENTS OF THE ACT SUICIDAL THOUGHTS TO REDUCE ACUTE RISK AND THEN PROVIDE THIS TREATMENT ACROSS THE CRITICAL WINDOW. WE KNOW THAT THERE ARE LONG TERM TREATMENTS THAT WORK. WE KNOW THAT DBT, CBT, LITHIUM WORK. CAN WE BRIDGE THIS GAP? CAN WE REDUCE SUICIDE RISK IN THE SHORT-TERM TO GET PEOPLE TO EFFECTIVE TREATMENTS TO REALLY SORT OF DIG IN THERE AND DO THE GOOD WORK TO REDUCE RISK OVER THE LONG TERM? AND AGAIN, THAT REALLY DOES ALLOW THIS TIME, ALLOW THE MINUTES, HOURS, TO DAYS TO CONNECT PATIENTS TO LONG TERM RESOURCES. SO, OVERALL, THERE IS A NUMBER OF PROBLEMS WITH OUR CURRENT ANTI-DEPRESSANTS. THERE IS LOW REMISSION RATES AND WE HAVE A LAG OF ONSET. THIS IS A VISUAL DEPICTION OF WHAT I WAS SAYING. OVERALL WE DO HAVE A LONG TIME UNTIL WE SEE THE ANTI-DEPRESSANTS START TO WORK AND WHAT WE ARE HOPING FOR IS TO THINK ABOUT THE NEXT GENERATION OF ANTI-DEPRESSANT AND POTENTIALLY ANTI-SUICIDAL IDEATION TREATMENTS THAT CAN HAVE THIS RAPID ONSET. SO BEFORE I GO ON TO THE NEXT SLIDE, I'M JUST CURIOUS. HOW MANY PEOPLE HEARD OF CATAMEAN IN A PSYCHIATRIC SETTING? SO I DON'T HAVE TO ALLUDE TO THIS AS UP MORE. I WANT THIS TALK TO REALLY FOCUS -- >> AUDIENCE MEMBER: (OFF MIC). >> 10-14 WEEKS OF LAG OF ONSET OF THE EFFECTS OF -- FULL EFFECTS OF SSRI. SO THE WORK THAT I DO, I WORK UNDER DR. CARLOS SER ATE WHO HAS BEEN INSTRUMENTAL AROUND THIS WORK. THIS IS NOT A KETAMINE FOCUSED INVESTIGATION. WANT TO COME UP AFTERWARDS ANDLE- ASK ME QUESTIONS, I'M HAPPY TO ANSWER MORE. REALLY BRIEFLY, KETAMINE HAS A LONGSTANDING HIT REUSED IN SURGERIES, USED MOST OFTEN WITH PEDIATRIC SURGERIES, INTERESTING ENOUGH. IT IS ALSO A POTENTIAL DRUG OF ABUSE. IT'S AN MMDA RECEPTOR ANTAGONIST AND THE HOW WE USE IT IS IT GIVEN INTERVENOUSLY. IT'S ONE OF THESE POTENTIAL NEXT GENERATION TREATMENTS AND WHEN YOU SEE EFFECTS, YOU DO SEE EFFECTS WITHIN MINUTES TO HOURS. IT HAS MORE OF AN EVIDENCE BASE WHICH MEANS A COUPLE MORE RANDOMIZED CLINICAL TRIALS AS ANTI-DEPRESSANT BUT WHAT IS DEVELOPING A LOT OF EXCITEMENT IS YOU ALSO SEE THIS POTENTIAL REDUCTION IN SUICIDAL THOUGHTS. I'M HIGHLIGHTING THIS ARTICLE THAT JUST CAME OUT THIS YEAR OF METANALYSIS OF THE CURRENT LITERATURE ON SUICIDE AND KETAMINE. SO THIS WAS 167 OF THOSE WHO REPORTED SUICIDAL THOUGHTS AND WE SAW REDUCTION WITH KETAMINE UP TO ONE WEEK. IT IS VERY EXCITING AND YOU MIGHT HAVE PATIENTS COMING IN ASKING YOU ABOUT IT. WE HAVE CLINICAL TRIALS RELATED TO IT BUT I WANT TO EMPHASIZE, THIS IS LESS THAN 200 PATIENTS IN THE PUBLISHED LITERATURE WITH SUICIDAL THOUGHTS THAT HAVE RECEIVED KETAMINE. AND FURTHERMORE THIS FOCUS IS ON ADOLESCENT SUICIDE. THE EVIDENCE SPACE MUCH LESS THAT THE POINT IN TIME. THERE IS A LOT OF WORK TO BE DONE TO UNDERSTAND IF ANYTHING. I THINK THE BLACK BOX WARNING HAS TAUGHT US WE NEED TO BE ABLE TO UNDERSTAND WHAT GOES ON WHEN ADOLESCENTS RECEIVE TREATMENT AS OPPOSED TO ADULTS. SO, I THINK THIS IS POTENTIAL PROMISE BUT I WOULD NOT AT THIS POINT IN TIME AS A FEDERAL EMPLOYEE, WANT TO ENDORSE SPECIFICALLY KETAMINE AS AN ANTI-SUICIDAL TREATMENT FOR ADOLESCENTS. SO, OVERALL, I THINK AGAIN IT'S A VERY EXCITING TIME TO BE IN THIS FIELD. AND SO I WANT TO TALK A LITTLE BIT ABOUT THE NEUROBIOLOGY AT NIH. SO, SINCE YOU'RE ALL HERE, YOU HAD TO -- I GUESS THE PEOPLE IN THE ROOM TO GET THROUGH SECURITY THIS MORNING. YOU KNOW WE ARE ON NIH'S CAMPUS. I WORK IN THE NIH CLINICAL CENTERS SO IT IS A DEDICATED RESEARCH FACILITY. WE DO NOT HAVE AN EMERGENCY ROOM. WE DO NOT HAVE PRY MARE I CARE. EVERYBODY WHO IS IN THIS SHOULDN'T HERE BECAUSE THEY ARE ON A RESEARCH PROTOCOL. WE HAVE 12 BEDS, ADULT BEDS, AND EVERYBODY IS FOCUSED ON MOOD DISORDERS, DEPRESSION, BIPOLAR OR ACUTE SUICIDE RISK. WE ARE EQUIPPED FOR THE STUDY. WE ARE ABLE TO TAKE PEOPLE OFF THEIR MEDICATIONS TO DO PRETTY IN-DEPTH CLINICAL TRIALS. SO I'M GOING TO TALK BELL THE SPECIFIC STUDY, NEUROBIOLOGY OF SUICIDE PROTOCOL OR WE CALL IT RISK, BECAUSE IT IS RESEARCH INVESTIGATION INTO THE SUICIDE CRISIS. MOSTLY BECAUSE WE DIDN'T WANT PATIENTS TO HAVE TO SAY THAT THEY WERE ON THE SUICIDE PROTOCOL. WHEN THEY WERE TALKING TO EACH OTHER. BUT BASICALY, WE HAVE FOUR PARTICIPANT GROUPS WE ARE RECRUITING. GROUP 1 IS INDIVIDUALS WITH A SUICIDE ATTEMPT OR SUICIDAL THOUGHTS WITH INTENT IN THE LAST TWO WEEKS. WE ALSO HAVE INDIVIDUALS WHO HAVE ATTEMPTED SOMETIME IN THEIR LIFE BUT NO SUICIDAL THOUGHTS OR BEHAVIORS IN THE LAST YEAR. WE ARE TRYING TO GET AT TRAIT VERSUS STATE MARKERS THERE. WE HAVE A GROUP OF PATIENT CONTROLS MEANING DEPRESSED ANXIOUS INDIVIDUALS WITH NO SUICIDE HISTORY. AND THEN HEALTHY CONTROLS. SO ABLE TO GO IN DEPTH BECAUSE OF THE RESOURCES AT NIH AND DO MULTIMODAL ASSESSMENTS TO REALLY UNDERSTAND THE NEUROBIOLOGY OF ACTIVE SUICIDE RISK. WE HAVE A COLLABORATION WITH LOCAL HOSPITALS. WE ARE ABLE TO RECRUIT SPECIFICALLY FROM SUBURBAN HOSPITALS BUT ABLE TO TAKE PATIENTS FROM AROUND THE AREA TO RECRUIT THESE PATIENTS INTO OUR STUDIES AND REALLY TRYING TO GET AT WHO IS THE BIOLOGY OF THE ACTIVE SUICIDE CRISIS AND WE ARE ABLE TO GIVE PEOPLE KETAMINE TO DO THESE MEASURES AGAIN TO UNDERSTAND IF KETAMINE IS WORKING, HOW IS IT WORKING IN THE BRAIN AND HOW IS IT WORKING WITH SLEEP? SO THE TYPICAL STRUCTURE OF THE RESEARCH PROTOCOL IS THAT SOMEBODY GOES TO A PSYCHIATRIC INPATIENT SETTING AND SEEKS TREATMENT IN THE COMMUNITY AND WE WANT THEM TO ALWAYS GO TO EMERGENCY SERVICES. THIS IS NOT -- WE DO NOT HAVE AN EMERGENCY ROOM. WE DO NOT HAVE A 24-HOUR CRISIS LINE PEOPLE CAN CALL US UP. WE REALLY DEVELOP THESE RELATIONSHIPS WITH CLINICIANS IN THE COMMUNITY TO POTENTIALLY IDENTIFY INDIVIDUALS WHO MIGHT BE INTERESTED AND ELIGIBLE FOR RESEARCH AND TRANSPORT THEM TO NIH. SO THEY ARE CONSENTED INTO VARIOUS PHASES OF STUDY. A NUMBER OF MEASURES. AGAIN THEY RECEIVED OPEN-LABEL KETAMINE AND THEN GET ADDITIONAL MEASURES. SO TO GIVE YOU THE SCOPE OF THE RESEARCH PROCEDURES AND THIS IS IN AN IDEAL CASE FOR ONE PARTICIPANT WITH ACTIVE SUICIDAL THOUGHTS, THESE ARE THE NUMBERS OF PROCEDURES WE WOULD DO. SO THAT INVOLVES INFORMED CONSENT, DIFFERENT LEVELS OF IMAGING, POOR SLEEP STUDIES, FIVE KETAMINE INFUSIONS AND NUMEROUS CLINICAL BLOOD DRAWS AND EXPERIMENTAL TESTS AND ADMINISTRATION OF ANXIETY AND THEN AN OPTIONAL LUMBAR PUNCTURE. IF YOU THINK FROM A RESEARCH PERSPECTIVE, IT'S A LOT TO COORDINATE AND THEN THINK ABOUT ADDING ON THE VULNERABLE POPULATION, INDIVIDUALS WHO MIGHT BE AT SIGNIFICANT SUICIDE RISK, YOU CAN UNDERSTAND WHY THIS MIGHT HAVE CAUSED A FAIR AMOUNT OF CONSTERNATION ON THE PART OF THE ADMINISTRATION AND POTENTIALLY THE IRB. SO NOW I'M GOING TO REVIEW THE PROCESS THAT WE WENT THROUGH TO ENSURE SAFETY OF OUR RESEARCH PARTICIPANTS BAH ALSO SAY ALL THESE PROCESSES ARE ONGOING. WE DID A LOT OF WORK AT THE FRONT END BUT IT'S STILL AN ONGOING PROCESS. SO THERE WAS A NUMBER OF QUESTIONS THAT CAME UP FOR US FROM AN ETHICAL PERSPECTIVE. HOW DO YOU EVEN CONSENT SOMEBODY INTO RESEARCH WITH ACTIVE SUICIDAL THOUGHTS? IF SOMEBODY IS COMING HERE AND SAYING THAT EVEN PART OF THEM WANTS TO DIE, HOW DO YOU THINK THROUGH HOW YOU ASSESS UNDERSTANDING, ASSESS THE DECISION TO TAKE PART OF RESEARCH? WE TRY TO KEEP IT AS LOW RISK AS POSSIBLE BUT YOU SAW THE RESEARCH TASKS THAT WE ASKED PEOPLE TO DO. IT'S NOT NOTHING. IT'S NOT JUST QUESTIONS. WE ARE ASKING THEM TO DO THINGS. SO HOW DO WE UNDERSTAND THAT PROCESS AND COME TO A DECISION THAT EVERYBODY FEELS COMFORTABLE TO ENROLL THIS PERSON INTO RESEARCH? PHYSICAL ENVIRONMENT. HOW DO WE ENSURE SAFETY OF SOMEBODY WITH SUICIDAL THOUGHTS? THIS IS NOT JUST ON A PSYCHIATRIC INPATIENT UNIT IT'S IN A SCANNER. IT'S IN A SLEEP STUDY. IT'S THROUGHOUT THE HOSPITAL. WE ARE BRINGING PEOPLE FOR DIFFERENT RESEARCH PARTIS -- PROCEDURES. HOW DO WE ENSURE SAFETY THAT WAY? AND THEN THROUGHOUT THE HEALTH CARE SYSTEM, HOW DO WE MANAGE ANXIETY AND EXPECTATIONS THROUGHOUT THE HOSPITAL? YOU GUYS HAVE WORKED IN CLINICAL SETTINGS AND YOU KNOW THE POTENTIAL IMPACT THAT JUST ONE SUICIDE CAN HAVE ON THE ENTIRE HOSPITAL SYSTEM. WE DID HAVE A SUICIDE THAT DID HAPPEN A NUMBER OF YEARS AGO AT NIH AND IT WAS STILL REMAINING ANXIETY 10 YEARS LATER ABOUT THIS OCCURRENCE AND COULD THIS HAPPEN AGAIN? SO HOW DID WE DO THIS? IT TOOK A WHILE. BUT THERE WERE A BE IN OF PROCESSES FOR ETHICAL RESEARCH. SO FIRST WE HAVE A DEPARTMENT OF BIOETHICS THAT CAN REVIEW THE ENTIRE PROTOCOL WITH US. WE HAD A CONSULTATION, TALKED THROUGH THE PROCESS WAS INFORMED CONSENT. THEY GAVE US GOOD GUIDANCE ON HOW TO DO THIS PROCESS. WE HAD EXTENSIVE CONSULTATION WITH THE IRB. OUR IRB GREW AND OUR GROUP HAS NEVER SEEN SO MANY STIPULATIONS AND GO AROUND THAT WE HAD TO DO BUT I THINK IT WAS VERY IMPORTANT WORK. WE HAD A GRAND ROUNDS HERE AT NIH ON RESEARCH ON SUICIDE. IS IT ETHICAL TO ENROLL INDIVIDUALS IN CRISIS? DR. ROSENSTEIN IS NOW AT UNC CHAPEL HILL BUT HE WAS THE CLINICAL DIRECTOR AND CAPE BACK TO TALK ABOUT THIS -- WE HAD EXTENSIVE TRAINING OF STAFF, INCLUDING IN-SERVICE WITH DR. DAVE JOBES OF PEOPLE IN THE AREA AND HAVE BEEN TO ONE OF HIS TRAININGS, HE IS AT CATHOLIC UNIVERSITY. HE WAS ABLE TO AND AND DO IN-SERVICE FOR OUR NURSES. AND WILL THEN WE DID A FAILURE, MODES AND EFFECTS ANALYSIS. WHICH I'LL GO INTO IN A SECOND FOR CLINICAL LEADERSHIP. SO, THE FAILURE MODES AND EFFECTS ANALYSIS, I'M NOT GOING INTO TOO MUCH DETAIL BUT JUST TO SAY THIS IS A PROCESS WHERE YOU IDENTIFY RISK PROSPECTIVELY, FORMAL PROCESS OF DISCUSSING RISK BEFORE IT BEGINS. GET PEOPLE INTO A ROOM AND THEN YOU COME UP WITH ALL OF THE DIFFERENT WAYS THINGS CAN GO WRONG. HOW PEOPLE CAN KILL THEMSELVES, HOW THIS COULD BLOW UP IN OUR FACES AND REALLY TRY TO IDENTIFY THEM PROACTIVELY AND THEN PRIORITIZE THEM AND SORT OF THINK THROUGH AN ACTION PLAN. SO THE IDEA IS IT'S GREAT TO DO THESE ROOT CAUSE ANALYSIS AFTER AN EVENT OCCURS BUT REALLY GETTING EVERYBODY INTO THE ROOM BECAUSE NURSING MIGHT HAVE A DIFFERENT SET OF CONCERNS THAN SOCIAL WORK THAN THE CLINICIANS, TO REALLY MAKE SURE WE ARE ON THE SAME PAGE. SO THIS IS AN EXAMPLE. WE HAD A LOT OF DIFFERENT -- WE HAD PEOPLE IN THE ROOM, LEADERSHIP FROM THE CLINICAL CENTER, OUR RESEARCH STAFF, MEDICAL NURSING, SOCIAL WORK COMING TOGETHER TO WORK ON THIS. THE TOP PRIORITIES THAT WE ADDRESSED FROM THIS PROCESS, ONE WAS DEFINITELY ENVIRONMENTAL RISK. ESPECIALLY WHEN WE BRING PATIENTS OFF THE UNIT. SO WE HAVE A NUMBER OF CHECK LISTS AND SAFETY PLANS SO WHEN WE BRING SOMEBODY TO A SCANNER, WE KNOW THE ROOM HAS BEEN SEARCHED IN A SIMILAR WAY. INADEQUATE STAFFING IS SOMETHING WE CONTINUE TO HAVE CONVERSATIONS WITH NURSING ABOUT. UNDETECTED SUICIDE RISK AND THAT REALLY LEADS INTO TRAINING OF STAFF, WHICH I ALLUDED TO BEFORE. SO IT REALLY WAS A FANTASTIC PROCESS FOR US. I WON'T LIE. IT WAS A LOT OF WORK BUT I THINK IT DID ALLOW US TO COME TOGETHER AND REALLY BE ON THE SAME PAGE. AND I THINK FROM MY PERSPECTIVE, IT EMPHASIZED HOW MANY PARTS OF THE HOSPITAL A SUICIDE CAN TOUCH. SO AS A RESULT OF THIS, WE REACHED OUT TO A NUMBER OF OTHER DISCIPLINES WE MET AND TRAINED WITH A NUMBER OF PEOPLE THROUGHOUT THE HOSPITAL FROM NURSING TO ADMISSIONS, PATIENT TRANSPORT, EVEN THE DIETARY SERVICES. SO IT REALLY BECAME A HOSPITAL-WIDE EFFORT RATHER THAN JUST A PSYCHIATRIC PROBLEM, WHICH I THINK WAS VERY IMPORTANT. SO, OVERALL, THE LESSONS LEARNED I BELIEVE THAT RESEARCH CAN SAFELY AND ETHICALLY BE COMPLETED WITH ACTIVELY SUICIDAL INDIVIDUALS. THERE IS AN EMPHASIS ON PHYSICAL ENVIRONMENT AND TRAINING THAT I THINK HAS TO HAPPEN. AND COMMUNICATION ALWAYS COMES DOWN TO COMMUNICATION AS ESSENTIAL BEFORE RESEARCH BEGINS. AND SO, I'M GOING TO SWITCH GEARS A LITTLE BIT AND TALK A LITTLE BIT ABOUT RESEARCH, BUT I WILL SAY IF ANYBODY IS INTERESTED IN HEARING MORE ABOUT THE STUDY AND RECRUITMENT, I'M HAPPY TO TALK TO YOU. WE ALSO HAVE A SOCIAL WORKER IN THE AUDIENCE ALSO INVOLVED WITH RECRUITMENT AND WE ARE HAPPY TO DISCUSS MORE BECAUSE ESPECIALLY FOR THESE GROUP 1 PARTICIPANTS, THEY VERY MUCH COME FROM PATIENTS LOCALLY. SO NOW I'M GOING TO TALK A LITTLE BIT ABOUT WHAT OUR RESEARCH IS STARTING TO SHOW BUT OBVIOUSLY WILL BE CONTINUING TO DEVELOP FINDINGS AS WE RECRUIT NEW PATIENTS. FIRST I'M GOING TO START WITH SUICIDE IDEATION AND SLEEP. SO WE KNOW IN GENERAL THAT SELF REPORTED SLEEP DIFFICULTIES ARE AN IMPORTANT RISK FACTOR FOR SUICIDE, OVER ALL AS ALLUDED TO BEFORE, INSOMNIA IS ASSOCIATED WITH FUTURE SUICIDE ATTEMPT AND DEATH. SO WE ESPECIALLY KNOW THIS OVER THE LONG TERM. OFTEN WEEKS OR MONTHS, ESPECIALLY IF YOU'RE LOOKING AT SUICIDE DEATH, YOU'RE ABLE TO SHOW THAT PEOPLE WHO REPORT INSOMNIA AT SOME POINT IN THEIR LIFE ARE AT HIGH RISK TO KILL THEMSELVES OVER THEIR LIFETIME. WE ARE ALSO INTERESTED IN IS THIS LIKE AN ACUTE -- TALKING ABOUT WARNING SIGNS VERSUS RISK FACTORS THAT DR. HOROWITS WAS ALLUDING TO S IT POTENTIALLY A MODIFIABLE RISK FACTOR FOR SUICIDE? THERE HAS BEEN SOME INVESTIGATIONS OF WHAT ARE THE HIGH-RISK TIMES FOR PEOPLE TO KILL THEMSELVES? IT'S THE TIME PERIOD BETWEEN MIDNIGHT AND 5:00 A.M. AND SO IF YOU THINK ABOUT WHAT IS GOING ON BETWEEN MIDNIGHT AND 5 A.M., ONE, YOU'RE SUPPOSED TO BE ASLEEP, SO IF YOU'RE AWAKE, YOU'RE PROBABLY SLEEP DEPRIVED. PEOPLE HAVE BEEN TALKING A LITTLE BIT ABOUT SOCIAL MEDIA AND PEOPLE MIGHT BE ON LINE. YOUR FRIENDS ARE NOT NECESSARILY AWAKE. YOUR THERAPIST IS NOT NECESSARILY THERE ON CALL. PEOPLE ARE MORE OFTEN MAYBE USING DRUGS, USING ALCOHOL. SO IF YOU THINK ABOUT WHAT IS HAPPENING OVER THE COURSE OF THE NIGHT, IT MIGHT BE A PARTICULARLY HIGH-RISK TIME FOR A NUMBER OF FACTORS, BIOLOGICALLY AND EVEN ENVIRONMENTALLY, IT LEADS THIS TO BE PARTICULARLY HIGH RISK TIME FOR SUICIDAL BEHAVIOR. WE DECIDED TO FOCUS ON THIS TIME. SO MIDNIGHT TO 5 A.M. IN A COHORT OF DEPRESSED PATIENTS THAT WE RULED ON. SO I'M GOING TO WALK YOU THROUGH THE GRAPHS. AGAIN FOCUSING ON MIDNIGHT TO 5:00 A.M. AND SO WE ARE ABLE TO DO SLEEP STUDIES SO THAT IS A SLEEP EEG WHERE WE ARE REALLY ABLE FROM A MINUTE TO MINUTE PERSPECTIVE ABLE TO ASSESS WHETHER PEOPLE ARE AWAKE OR ASLEEP OVER THE COURSE OF THE NIGHT. SO WHAT YOU HAVE IS WAKE FULLNESS IN DEPRESSED PATIENTS. YOU CAN SEE THAT EACH LINE REPRESENTS THE SLEEP OF ONE PERSON. SO OVERALL YOU SEE A LOT OF WAKE FULLNESS IN THESE DEPRESSED INDIVIDUALS. AND IN CONTRAST, YOU SEE WAKE FULLNESS IN A SAMPLE OF INDIVIDUALS WITHOUT PSYCHIATRIC DIAGNOSIS. SO HEALTHY CONTROLS. SO YOU SEE MUCH LESS WAKE FULLNESS OVER THE COURSE OF THE NIGHT. SO WHAT I DID -- WE LOOKED AT WHO THEN REPORTED SUICIDAL THOUGHTS THE NEXT MORNING. SO AGAIN WE WERE TALKING ABOUT LONG TERM RISK FACTORS AS OPPOSED TO OVER THE COURSE OF HOURS. AND SO WHAT YOU SEE, AND I APOLOGIZE TO THE PEOPLE ON MY RIGHT FOR THIS. YOU SEE THE WAKE FULLNESS IN DEPRESS IDEAIARITIES VERSUS. YOU SEE A SIGNIFICANT INTERACTION. SPECIFICALLY TIME SPENT AWAKE AT 4 A.M. PREDICTED SUICIDAL THOUGHTS THE NEXT DAY. EVEN WHEN YOU CONTROLLED FOR GENDER, AGE, DIAGNOSIS, DEPRESSION SEVERITY, YOU STILL SAW THIS DIFFERENCE. IT WAS SOMETHING ABOUT IN THIS MODEL, BEING AWAKE DURING THIS CERTAIN TIME PREDICTED SUICIDAL THOUGHTS THE NEXT MORNING. THEN WE LOOKED AT WHAT HAPPENED AFTER KETAMINE. SO AGAIN, IT IS ASSOCIATED WITH RAPID REDUCTIONS AND SUICIDAL THOUGHTS. ON THE LEFT YOU HAVE PATIENTS WITHOUT AN ANTI-SUICIDAL RESPONSE TO KETAMINE. THEY REPORT SUICIDAL THOUGHTS, GET KETAMINE AND WAKE UP THE NEXT MORNING AND STILL REPORT SUICIDAL THOUGHTS. THE THE SIDE IS THE PATIENTS WITH THE ANTI-SUICIDAL THOUGHTS TO KETAMINE. THEY GO TO SLEEP, WAKE UP THE NEXT MORNING AND NO LONGER REPORT ANY WISH TO DIE. AND SO WHAT CAN YOU SEE HERE IS THERE IS A MARKED DIFFERENCE EVEN WHEN YOU ADJUST FOR BASELINE SLEEP. I ALWAYS SAY WHEN I FIRST PRESENTED, SOMEBODY SAID YOU MESSED UP THE GRAPHS. THIS IS CLEARLY JUST THE HEALTHY CONTROL GRAPHS. IT'S NOT. I CHECKED A MILLION TIMES. THE SO OVER ALL YOU DO SEE THIS POTENTIAL NORMALIZATION OF SLEEP AFTER KETAMINE AND REALLY SORT OF POINTS TO THE FACT THAT SLEEP MIGHT BE THIS ACUTE RISK FACTOR THAT IS PARTICULARLY IMPORTANT EVEN OVER THE COURSE OF JUST SEVERAL DAYS. SO, THIS IS LEADING US TO THINK THE ROLE OF SLEEP IN KETAMINE AS WELL AS SUICIDE RISK. SO, THE LAST THING I'M GOING TO FOCUS ON IS THE SUICIDE IMPLICIT ASSOCIATION TASK. SO LIKE I SAID BEFORE, DOCTOR BRENT ALREADY ALLUDED TO THIS. THE IAT WAS DEVELOPED FROM THE SOCIAL PSYCHOLOGY LITERATURE. IF PEOPLE WANT TO FIND OUT ABOUT THEIR OWN IMPLICIT BIASES, HARVARD HAS A GREAT SITE YOU CAN FIND ALL SORTS OF IMPLICIT BIASES FROM A SOCIAL PSYCHOLOGY PERSPECTIVE. BUT MATT KNOCK WAS THE PERSON TO REALLY BRING SUICIDE INTO THIS PARTICULAR TOPIC. AND WHAT HE WAS ABLE TO SHOW JUST A BEHAVIORAL VERSION OF THIS TASK FOR THE MOST PART, IT IS FIVE MINUTES AND I'LL EXPLAIN A LITTLE BIT ABOUT THE STRUCTURE, HAS BEEN SHOWN TO PREDICT SUICIDE ATTEMPTS AT 6 MONTH FOLLOW-UP. SOMETIMES EVEN BETTER THAN CLINICIAN ASSESSING ITSELF SO THEY PUT, CAN THIS COMPUTERIZED MORE OBJECTIVE TASK POTENTIALLY PREDICT BETTER THAN CLINICIAN'S ASSESSMENT AND POTENTIALLY IT CAN. AND OVERALL, WE ARE SEEING NO EVIDENCE OF AT GENEIC EFFECTS OF THE IAT, WHICH IS ALWAYS A CONCERN WHEN YOU'RE SHOWING PEOPLE A LOT OF WORDS THAT HAVE TO DO WITH DEATH. SO, OVERALL, AND SO AGAIN THIS IS A SUMMARY OF WHAT WAS DESCRIBED BEFORE. THE COMPUTERIZED TASK IS YOU HAVE TWO AREAS, DEATH OR ME AND DEATH OR NOT ME. HERE AND HERE. AND THEN YOU RECEIVE A TARGET WORD. SO PARTICIPANTS ARE ASKED TO CATEGORIZE THE WORD INTO LEFT OR RIGHT GROUPS. SO AN EXAMPLE WORD IS SUICIDAL. YOU PUT IT IN THE DEATH OR ME CATEGORY. THIS IS WHAT HAPPENS OVER THE COURSE OF CERTAIN BLOCKS. AND THEN AT SOME POINT, THE CATEGORIES CHANGE AND WHAT WE FIND OUT IS THAT THE PEOPLE AT THE HIGHEST SUICIDE RISK ARE FASTER TO CATEGORIZE WORDS IN THIS CONDITION, THE DEATH OR ME THAN THE LIFE OR NOT ME CONDITION. Y IS IT'S JUST GETTING AT THE IMPLICIT ASSOCIATION. YOU'RE NOT NECESSARILY ASKING PEOPLE SPECIFICALLY TO TALK ABOUT THIS ASSOCIATION BETWEEN THEMSELVES AND DEATH BUT IT IS REALLY A TEST OF REACTION TIME. SO, WHAT WE HAVE BEEN WORKING ON IS ADAPTING THE TASK FOR USE IN FMRI. AND WE ARE GOING TO USE IT IN MEG AS WELL. SO IN COLLABORATION WITH MATT AND DAN, WE PILOTED THIS TASK IN A SAMPLE OF 27 HEALTHY VOLUNTEERS AT 3TFMRI. FIRST WE WANTED TO SEE WOULD THIS WORK? ROUGHLY COMPARABLE TO THE BEHAVIORAL RESULTS FROM THE FMRI VERSION TO WHAT WE ARE SEEING OUTSIDE OF THE SCANNER AND THEN SEE ARE THERE DIFFERENT BRAIN PATTERNS? IS THIS SOMETHING THAT MIGHT BE USEFUL TO STUDY IN CLINICAL SAMPLES? AND SO OVERALL, WE DO SEE THAT THE BEHAVIOR RESULTS OVERALL IN TERMS OF WHAT WE FIND IN OUR SAMPLE VERSUS SAMPLES -- IAT IS A VERY EXCITING TOPIC. PEOPLE ARE STUDYING IT ALL OVER. OVERALL WE ARE SEEING COMPARABLE RESULTS. AND WILL ALSO IN TERMS OF IMAGING RESULTS WE ARE SEEING GREATER ACTIVATION IN CERTAIN AREAS IN THE SELF DEATH THAN THE SELF LIFE CONDITION. OBVIOUSLY, THIS IS JUST A HEALTHY CONTROL SAMPLE. WE HAVE NOT DONE IT IN CLINICAL SAMPLES. WE DON'T QUITE UNDERSTAND WHAT THESE PARTICULAR FINDINGS MEAN. WE DO SEE A PARTICULARLY IMPORTANT REGION FOR EMOTIONAL PROCESSING, ANTERIA INSULA IS HIGHLIGHTED. I'M GOING TO GIVE THIS EXAMPLE SO THIS IS THE SELF DEATH CONDITION. AND THEN THE SELF LIFE. AND SO YOU CAN SEE DIFFERENTIAL PATTERNS OF ACTIVATION. SO WHAT WE DON'T KNOW, THAT WE ARE TRYING TO FIGURE OUT RIGHT NOW, IS WHAT HAPPENS IF YOU GIVE THIS TO A SUICIDAL INDIVIDUAL? DO YOU SEE POTENTIALLY THESE PATTERNS REVERSED? IT IS REALLY GOING BACK TO THE STUDY OF MACHINE LEARNING THAT DR. BRENT WAS TALKING ABOUT, UNDERSTANDING HOW SUICIDAL INDIVIDUALS PROCESS WORDS, PROCESS CERTAIN CONCERTS THAT MIGHT BE DIFFERENT IN CLINICAL SAMPLES VERSUS HEALTHY CONTROLS. I THINK THAT OVERALL, I THINK THE AREAS OF FUTURE EXCITING RESEARCH INCLUDE SLEEP AND IMPLICIT SUICIDE RISK BUT I THINK THERE IS SO MUCH MORE WE NEED TO KNOW AND THAT HOPEFULLY WE WILL CONTINUE TO KNOW OVER THE NEXT 5-10 YEARS. SO THIS IS COMPLETED BY A VERY LARGE GROUP OF PEOPLE. I HAVE TO ACKNOWLEDGE MY PI AND LAURA WHO DOES THE SOCIAL WORK RECRUITING AND THE OFFICE OF THE CLINICAL DIRECTOR IN OUR NURSING. SO I DON'T KNOW IF WE ARE TAKING QUESTIONS AT THE END, BUT THANK YOU FOR YOUR ATTENTION. [ APPLAUSE ] >> THANK YOU. REALLY TWO WONDERFUL ADDITIONAL TALKS TO DR. BRENT'S EXCELLENT OPENING. I HAVE TO SAY THAT FROM THE INCEPTION OF THINKING ABOUT THIS WORKSHOP, DR. ARGYRIS STRINGARIS WAS REALLY CLEAR ABOUT THE VALUE OF EXPANDING WHAT WE LEARNED NOT JUST FROM INVESTIGATORS AND CLINICIANS BUT FROM SOMEONE IN THE COMMUNITY. AND THE WE WERE EXTRAORDINARILY LUCKY THAT Mrs. ROGERS WAS WILLING TO COME AND SPEAK TO US AND IT'S MY PLEASURE TO INTRODUCE HER TO YOU NOW. Mrs. ANN MOSS ROGERS HAS A LIFELONG CAREER IN MARKETING. IS A SOCIAL MEDIA AND CONTENT MARKETING EXPERT, AND WAS A CO-OWNER OF A SUCCESSFUL DIGITAL MARKETING FIRM, WHICH SHE SOLD IN JANUARY, 2017 TO FOCUS ON MENTAL HEALTH ADVOCACY FULL-TIME. SHE HAS BEEN ON THE BOARD FOR BEACON TREE FOUNDATION, ADVOCATES FOR YOUTH MENTAL HEALTH SINCE 2010, AND IS CURRENTLY ITS PRESIDENT. SHE HITS ALL TABOO SUBJECTS HEAD ON, GRIEF, DEPRESSION, ADDICTION, ON HER PERSONAL BLOG "EMOTIONALLY NAKED." ANN MONTHS IS A NATIVE OF NORTH CAROLINA, A GRADUATE OF THE UNIVERSITY OF NORTH CAROLINA-CHAPEL HILL, WITH A BACHELOR'S DEGREE IN JOURNALISM. AND SHE MOVED TO RICHMOND, JUDGE INIA, TO START A CAREER IN ADVERTISING STARTING AT THE MARTIN AGENCY. SHE HAS BEEN MARRIED OVER 30 YEARS TO HER HUSBAND, RANDY AND HER OLDEST SON, RICHARD, IS LIVING HIS DREAM AS A FILMMAKER IN LOS ANGELES. I'M DELIGHTED TO HAVE Mrs. ROGERS SPEAK TO US NOW. [ APPLAUSE ] >> CAN EVERYBODY HEAR ME? I HAVE A VOICE ISSUE LATELY AND I'M NOT -- AS EASILY HEARD AS I USUALLY AM. SO I APOLOGIZE FOR THE FROGGY VOICE. SO, I WANT TO INTRODUCE YOU TO MY SON, CHARLES. HE WAS THE FUNNIEST AND MOST POPULAR KID IN SCHOOL. YET THE FUNNIEST AND MOST POPULAR KID IN SCHOOL SUFFERED FROM DEPRESSION, ADHD, ANXIETIY, BECAME ADDICTED TO HEROIN AND DIED BY SUICIDE. THIS WAS ACTUALLY A PRETTY PROUD MARIE EVANGELISTA: MOMENT. HOMECOMING COURT. AND MY OLDER SON, ACTUALLY WON HOMECOMING KING. SO I'M ESCORTING THE HOLDER CHILD. SO CHARLES IS ENTERTAINING HIS FAVORITE TEACHER. HE IS TELLING JOKES, MAKING HER LAUGH, AS THEY WALK ACROSS THE FIELD. AND IT IS ONE OF MY FAVORITE, FAVORITE PICTURES. BUT IT WAS NOT LONG AFTER THIS PICTURE WAS TAKEN THAT I NOTICED SOME CHANGES IN CHARLES. ALWAYS WANTING TO PARTICIPATE AND ENJOY A LOT OF ACTIVITIES, THAT STARTED TO DROP-OFF. WHAT'S WORSE IS HIS DRUG USE STARTED TO ESCALATE. AND I COULDN'T FIGURE OUT, IS THIS MENTAL ILLNESS? IS THIS DRUG PROBLEM? IS IT BOTH? I DIDN'T KNOW. SO WHAT HAPPENED WAS THAT THAT DRUG USE STARTED TO ESCALATE AND IT STARTED TO BECOME VERY DANGEROUS. AND HE STARTED TO HAVE A VERY CAVALIER ATTITUDE ABOUT LIFE, WHICH I WOULD FIND OUT LATER WAS INDICATED DEPRESSION BUT NOBODY EVER TOLD ME THAT. IN FACT, I TOOK MY SON TO NO FEWER THAN 14 MENTAL HEALTH PROFESSIONALS AND NOBODY EVER SAID THE TWO WORDS, PSYCHOLOGICAL EVALUATION. DURING THIS TIME, HE WAS ALSO DIAGNOSED WITH DELAYED SLEEP SYNDROME, A SLEEP DISORDER, WHICH IS INTERESTING THAT DR. BALLARD WOULD BRING THAT UP IN THIS ARENA. SO WE KNEW THAT HE HAD HAD THAT SINCE HE WAS TWO. SO HE HAD ALWAYS HAD A DIFFICULT TIME SLEEPING. ALL OF THIS STARTED TO HAPPEN AND THEN THIS INFLUX OF PARTY DRUGS CAME INTO RICHMOND, VIRGINIA WHERE HE WAS IN HIGH SCHOOL. AND I HAD SPY WEAR ON HIS COMPUTER AND I NOTICED HE WAS EXPERIMENTING WITH THESE VERY DANGEROUS PSYCHEDELIC DRUGS AND A LOT OF KIDS WERE TAKING THEM AFTER ONE HIT WOULD DIE. SO WE HAD TO TAKE THE DRASTIC MEASURE OF PLANNING TO KIDNAP MY SON OUT OF HIS BED AND TAKE HIM TO A WILDERNESS PROGRAM. YOU DON'T DO THIS BECAUSE YOU CAUGHT YOUR KID WITH BEER AND A JOINT. YOU DO THIS BECAUSE YOU REALLY THINK THAT YOUR CHILD'S LIFE IS AT RISK. AND AS YOU CAN SEE IN THE PICTURE, HE DIDN'T LOVE WILDERNESS. THERE WERE NO SHOWERS. THERE WERE NO iPODS. THERE WERE NO ELECTRONICS. BUT I HAD TO SAY AT THE END OF THE 10 WEEKS THAT HE WAS THERE, WHICH WAS ALMOST A RECORD AT 475 DOLLARS A DAY, THAT HE REALLY, I THINK HE DISCOVERED SOMETHING ABOUT HIMSELF. NOW THIS IS WHERE WE GOT A CLEAR PSYCHOLOGICAL EVALUATION AND DIAGNOSIS. SO, THEY DETERMINED THAT HE SUFFERED FROM DEPRESSION, ADHD COMBINED TYPE, CANNABIS DEPENDENCE AND ANXIETY. SO FOR THE FIRST TIME, I HAD A DEFINITIVE DIAGNOSIS. SO THEIR NEXT RECOMMENDATION WAS THAT HE GO TO THERAPEUTIC BOARDING SCHOOL. SO IF I THOUGHT THIS STEP WAS EXPENSIVE, THAT WAS 70 GRAND A YEAR. BUT WE HAD TO TAKE THAT. WHOSE GOING TO NOT CHOOSE TO DO THAT IF THEY CAN POSSIBLY STRETCH AND DO IT, RIGHT? I MEAN YOU'RE TRYING TO SAVE YOUR CHILD'S LIFE. SO THE NEXT STEP, HEAVE WENT TO THERAPEUTIC BOARDING SCHOOL AND ULTIMATELY, HE GRADUATED FROM THAT ACADEMY IN UTAH, A NON THERAPEUTIC BOARDING SCHOOL. THE TROUBLE WAS, I BROUGHT MY SON BACK TO THE STATE RANKED 49th FOR TREATING CHILDHOOD MAJOR DEPRESSION. NOW AT THIS POINT, HE IS 19. I'M HAVING A DIFFICULT TIME FINDING A PSYCHIATRIST THAT WILL SEE THEM UP TO AGE 18 AND AFTER 21. BUT THOSE GAP YEARS ARE EXCEPTIONALLY DIFFICULT TO GET PSYCHIATRIC CARE. AND IT PROBABLY TOOK ME AROUND SIX MONTHS TO FIND A PSYCHIATRIST. UNFORTUNATELY, IN THAT TIME, MY SON BECAME ADDICTED TO HEROIN. I DIDN'T KNOW IT. HE WAS NOT -- HE DIDN'T USE NEEDLES SO THERE WAS NO TINFOIL AND NEEDLES HANGING AROUND THE HOUSE. HE NORMALITIED IT. I WAS NOT -- HE SNORTED IT. I WAS NOT EVEN AWARE THAT PEOPLE COULD SNORT HEROIN. SO JUNE 5, 2015, MY HUSBAND AND I ARE AT A RESTAURANT IN RICHMOND, VIRGINIA AND WE ARE EATING DINNER. WHAT HAD HAPPENED IS THAT CHARLES HAD ENDED UP ASKING FOR HELP FOR HIS OPIATE ADDICTION AND HE HAD ENDED UP GOING TO DETOX. HE WENT TO REHAB. HE WAS IN A RECOVERY HOUSE. AND HE WAS ONE DAY IN THAT RECOVERY HOUSE AND HE RELAPSED. THEIR PROTOCOL WAS TO TAKE THEM BACK TO DETOX. AND HE WENT BACK, CHECKED IN, AND THEN HE SAW A FRIEND OF HIS. ONE MORE PARTY. I JUST WANT ONE MORE PARTY. AND HE LEFT. FOR TWO WEEKS, WE DIDN'T KNOW WHERE HE WAS. SO WE ARE SITTING IN THIS RESTAURANT AND MY HUSBAND GETS A CALL FROM THE POLICE ON HIS CELL PHONE. AND I'M LIKE, THAT'S KIND OF WIERD. AND THEY MET US IN THE PARKING LOT OF THIS RESTAURANT. AND IN THE BACK OF THE POLICE CAR, MY HUSBAND IN THE FRONT, THE POLICE SAID, WE FOUND YOUR SON DEAD IN AN APARTMENT ON MONUMENT AVENUE AT THE BOTTOM OF MY WORLD DROPPED OUT. AMIDST ALL OF THE WALES OF AGONY, MY HUSBAND TOOK A MOMENT AND HE GOES, HOW DID HE DIE? AND FOR SOME ODD REASON, I THINK WHAT A WIERD QUESTION. OF COURSE HE DIED OF OVERDOSE. BUT THE POLICE MAN SAID HE DIED BY SUICIDE. AND I LOOKED IN THE FRONT SEAT AND THERE IS MY HUSBAND JUST FALLING APART AND I CAN'T EVEN BREATHE. I START BRUSHING AWAY MY SKIN, AND I THINK IF I JUST BRUSH-OFF THIS SKIN, I WON'T BE ME AND I WON'T BE HEARING THIS AWFUL, AWFUL NEWS. SO, IN THE COMING DAYS, AND MONTHS, AS A FAMILY, WE HAD TO ACCEPT WHAT HAPPENED. AND I WAS UPSET BECAUSE NOBODY AFTER THE MEMORIAL SERVICE, WAS TALKING ABOUT MY CHILD BECAUSE HE HAD DIED BY SUICIDE. I GUESS THEY THOUGHT I ERASED HIM FROM MY FAMILY TREE. NOBODY MENTIONED HIS NAME. AND WHEN I WOULD BRING HIM UP, THEY WOULD CUT ME OFF. I HAD HAD ENOUGH. I HAD ENOUGH OF THIS STIGMA. ENOUGH OF THE SHAME. ENOUGH OF THE SILENCE THAT WENT WITH MENTAL ILLNESS AND ADDICTION. AND I WAS NEVER EVER GOING TO BE SILENT ON THIS SUBJECT EVER AGAIN. SO THE FIRST THING I DID IS WROTE THIS NEWSPAPER ARTICLE. SIX AGONIZING MONTHS TO WRITE THIS NEWSPAPER ARTICLE HONORING MY SON THAT DIED BY SUICIDE IS NOT THE END OF MY STORY. AND I TOLD THE STORY TRUTH AND ALL. IT'S PRETTY RAW. AND WHEN I WROTE IT, I THOUGHT NOBODY WILL EVER READ THIS. I DIDN'T CARE. IT WENT VIRAL AND IT BECAME THE NUMBER 1 ARTICLE OF 2016. WHAT I DIDN'T REALIZE IS OTHER PARENTS WERE READING THEIR STORY IN MINE. I WAS NOT ALONE. AND ITS ORIGINAL LOCATION, IT GOT OVER 2000 COMMENTS. IT HAS SINCE BEEN MOVED AND STILL HAS A LOT. SO RIGHT BEFORE I WROTE THAT ARTICLE, I REALIZED HOW MUCH WRITING IS HELPING ME. SO I STARTED THIS BLOG CALLED EMOTIONALLY NAKED AND BASICALLY, I GRIEF IN PUBLIC BECAUSE GRIEVE IS YET ANOTHER THING THAT WE DON'T EVER WAN WANT TO TALK ABOUT. I TALK ABOUT ALL THE TABOO SUBJECTS, SUITED AND MEANTAL ILLNESS AND NOW HAVE GUEST WRITERS WHO TELL OF THEIR EXPERIENCE EITHER LOSING A CHILD OR LIVED EXPERIENCE. SO HOW DO YOU GO FROM CUTE, ADORABLE, FUN, BUBBLY, TO ADDICTED TO HEROIN, SUFFERS FROM DEPRESSION, AND TAKES HIS OWN LIFE? I THINK FIRST OF ALL, WE NEED TO UNDERSTAND THAT EARLY INTERVENTION WORKS. THERE ARE SIGNS OF DEPRESSION IN CHILDREN EARLY. IF WE CAN INTERVENE AT THAT TIME WE CAN HAVE A POSITIVE RESULT. KIDS WANT TO TELL. AND THAT IS SOMETHING THAT I DID NOT REALIZE THAT THEY WANT TO TALK ABOUT. AS WE HEARD, FROM DR. HOROWITS. I'M GOING TO SHOW YOU JUST THREE OF THE SEVEN OF MY SON'S LAST WEEKS. IF I DIED NO ONE WOULD NOTICE FOR AT LEAST A MONTH. IF YOU WANT TO SEE WHO REALLY CARES ABOUT YOU, SEE WHO IS THERE WHEN YOU HAVE NOTHING. DEATH SOUNDS NICE. YOU'RE PROBABLY WONDERING WHY DIDN'T I DO SOMETHING WHEN I SAW THESE? I SAW THEM, MIXED UP WITH A LOT OF OTHER TWEETS. BUT NOBODY HAD EVER SAID, BY THE WAY, IF YOUR CHILD SUFFERS FROM DEPRESSION AND ADDICTION, HE IS SIX TIMES MORE LIKELY TO TAKE HIS LIFE. I THOUGHT THESE WERE SIGNS THAT HE WAS HEADING TO ROCK BOTTOM. WE'D GET TO PICK HIM AND HE WOULD TELL US WHERE HE WAS AND WE COULD PICK HIM UP THAT WEEKEND. BUT THAT'S NOT WHAT HAPPENED, OBVIOUSLY. SO ABOUT A MONTH BEFORE HIS DEATH ANNIVERSARY, I WAS REALLY SUFFERING AND I WROTE THIS POST ON MY BLOG CALLED, THE FINAL 48 HOURS. AND I DID NOT POST THIS ON FACEBOOK AND I POST ALMOST EVERYTHING ON FACEBOOK BECAUSE I WAS ASHAMED OF REVEALING MY UGLY, NAKED MARIE EVANGELISTA: NAKE NAKED GRIEF TO THE WORLD. SOMEBODY ELSE SHARED BECAUSE I HAVE A LOT OF SUBSCRIBERS. AND 16,000 PEOPLE CAME BY NOON THE NEXT DAY TO READ THAT ARTICLE. AND I THOUGHT, WHY ARE PEOPLE READING IT? WHAT IS MORE? WHY DID I WRITE IT? THEN I GOT A MESSAGE FROM A GIRL NAMED LAUREN AND IT SAYS SAID, TWO DAYS AGO I THOUGHT ABOUT TAKING MY LIFE. BUT READING A POST FROM A MOTHER WHO FELT SUCH DEVASTATING PAIN HAS CHANGED MY PERSPECTIVE ON LIFE. AND NOW I'M GOING TO DO ABSOLUTELY EVERYTHING SO THAT MY PARENTS NEVER FEEL THE WAY YOU DO NOW. AND SHE WENT TO HER MOTHER AND FATHER AND SHE ASKED FOR HELP AND THIS CHILD IS DOING WELL. SHE IS DOING WELL BECAUSE SHE WAS LOOKING ON LINE FOR VALIDATION TO TELL SOMEONE. AND SOMEHOW I FEEL PART OF THAT SUCCESS. AND SO DO ALL MY FOLLOWERS AND SUBSCRIBERS BECAUSE I WOULDN'T HAVE REACHED HER IF SO MANY PEOPLE HAD NOT SHARED THOSE ARTICLES. SO THAT GOT ME TO THINKING. ALL RIGHT, I CAN REACH THEM IN SOCIAL MEDIA. WHAT IF I COULD REACH THEM IN THAT MOMENT WHEN THEY ARE REALLY THINKING ABOUT DYING AND THEY ARE LOOKING UP WAYS TO DIE? I KNOW HOW TO RANK ON THE FIRST PAGE OF GOOGLE. I'M A DIGITAL MARKETING SPECIALIST. THAT'S MY EXPERTISE. HOW CAN I MEET THEM IN THAT MOMENT? SO I WROTE THIS POST. AND I WROTE THIS POST WITH THE EXPRESS PURPOSE OF RANKING ON THE FIRST PAGE OF GOOGLE. AND I DO. 225 COUNTRIES I AVERAGE ABOUT NUMBER 8. TWO HOW 400 PEOPL2400 PEOPLE COME TO THIS PAGE EVERY 30 DAYS. I DON'T TELL THEM HOW TO COMPLETE THIS. I HAVE A SUICIDE TRAINING SO I CONNECT WITH THE PAIN FIRST AND ON THIS PAGE IS A VIDEO FROM MY SON THAT SEVERAL PEOPLE WHO HAVE BEEN IN CRISIS HAVE TOLD ME HAVE SAVED THEIR LIVES. SO I PUT THAT. I ALSO PUT BREADCRUMBS FOR THEM TO GO TO MORE PAGINGS AND MORE PAGES. AND LOTS OF TIMES THEY STAY. SO 90% COME IN AND LEAVE. BUT 10% STAY FIVE MINUTES, SEVERAL HOURS, EVEN SEVERAL DAYS DAYS. SO IT WASN'T LONG AFTER I PUT UP THIS POST, AND ITCHES CHECKING THE STATISTICS, BUT NOBODY WAS MAKING ANY COMMENTS. AND I THOUGHT, I WONDER IF ANYBODY WILL EVER MAKE A COMMENT? AND THEN I GOT ONE FROM A GUY NAMED MATT AND IF YOU LOOK UP THAT POST AND SCROLL ALL THE WAY TO THE BOTTOM, YOU'LL READ MAT'S COMMENT. WHEN I GOT THAT COMMENT, I NEVER CRIED SO HARD IN ALL MY LIFE. HE BASICALLY TELLS ME IN THAT POST THAT I HAD GIVEN HIM HOME AND THAT HE LOVED READING ABOUT CHARLES AND THAT HE HAD AN EXCUSE TO LIVE ANOTHER DAY. I THOUGHT, THIS IS SOMETHING I CAN DO AS A GRASSROOTS EFFORT. I CAN'T STOP. I KNOW WHAT THE WORDS THEY USE TO LOOK THESE THINGS UP. I KNOW HOW TO FIGURE THAT OUT. SO HOW DO THEY GET THERE? THEIR PHONES, THEIR TABLETS, THEIR DESKTOPS. THIS PERSON GOT THERE THROUGH THE NINTENDO GAME CONSOLE. THEY LOOKED UP THAT PHRASE. AND FOR SOME REASON, THAT REALLY GAVE ME PAUSE. I THINK THE REASON WE ARE SEEING MORE SUICIDE IS THE BREAKDOWN OF COMMUNITY AND THE LACK OF CONNECTION. YOU GO INTO A NEIGHBORHOOD, YOU DON'T SEE PEOPLE PLAYING DODGE BALL, BASKETBALL. YOU DON'T SEE TEENAGERS ACTUALLY INTERACTING WITH EACH OTHER AS MUCH. IN FACT, 45% LESS FACETIME, 11-15-YEAR-OLD GIRLS AND BOYS SPEND THAT MUCH LESS FACETIME WITH THEIR FRIENDS. I THINK THAT IS WHAT IS HAVING A NEGATIVE EFFECT, WHETHER IT IS BECAUSE OF SOCIAL MEDIA OR BECAUSE OF TECHNOLOGY. WHATEVER IT IS. LESS CONNECTION. THAT'S SOMETHING WE CAN DO SOMETHING ABOUT TOMORROW. WE CAN HAVE THAT BONFIRE WHERE ALL THESE TEENS CAN COME OVER. WE CAN PLAN A HIKE FOR OUR TEENAGERS AND HAVE THEM -- WITH ALL THEIR FRIENDS GO OUT TOGETHER. AS TALENTED AND FUNNY AS MY SON, CHARLESs CHARLES, WAS, HIS GREATEST GIFT WAS LETTING OTHER PEOPLE KNOW THAT THEY MATTER. AND THAT IS A LEGACY I NEED TO CARRY FORWARD. I AM EASY ENOUGH TO FIND. IF YOU LOOK UP MY NAME, I'M SCARY ON GOOGLE. I'M THERE SO MANY TIMES. AND I HOPE THAT YOU WILL FOLLOW MY BLOG AND SHARE THAT AND I APPRECIATE YOU HAVING ME TODAY. BECAUSE I THINK THIS IS A BIG STEP BY THE NATIONAL INSTITUTE OF MALE AND THANK YOU FOR HAVING ME. [ APPLAUSE ] >> THANK YOU VERY, VERY MUCH FOR THIS. IT WAS VERY IMPORTANT TO US TO HEAR YOU PRESENT TODAY. THANK YOU. WE APPRECIATE IT VERY MUCH. WE WILL NOW HAVE A PANEL DISCUSSION. AND I WOULD LIKE TO ASK THE SPEAKERS TO COME FORWARD AND SIT AT THE TABLE, IF THAT IS ALL RIGHT. AND AS YOU'RE DOING THIS, I WOULD LIKE TO INTRODUCE OUR MODERATOR FOR THIS PANEL, DOCTOR STEPHEN GILMAN. DR. GILMAN IS THE ACTING BRANCH CHIEF AT THE NATIONAL INSTITUTE OF CHILD HEALTH AND DEVELOPMENT. HE ARRIVED HERE FROM HARVARD APPROXIMATELY TWO YEARS AGO. HE OBTAINED HIS MASTERS AND HIS DOCTORAL DEGREE AT HARVARD BEFORE HE WENT TO BROWN UNIVERSITY TO DO A POSTDOCTORAL STUDY. WE ARE VERY FORTUNATE TO HAVE HIM HERE TODAY. HE IS AN EXPERT ON DEVELOPMENT AND THE ADVERSE OUTCOMES THAT ARE ESTABLISHED EARLY IN LIFE, EVEN PRENATALLY. HE IS ABOUT TO CONDUCT WHAT I'M SURE WILL BECOME A MILESTONE STUDY IN THIS AREA IN UNDERSTANDING LATER ADVERSE DEVELOPMENTS THROUGH PRENATAL ADVERSITY. AND THERE COULDN'T BE A BETTER PERSON TO MODERATE TODAY'S DISCUSSION. THANK YOU VERY MUCH DR. GILMAN. [ APPLAUSE ] >> I WANTED TO COMMENT TO Mrs. ROGERS. WE HAD THE OPPORTUNITY TO RAISE OUR HANDS EARLIER IN THE DAY TO, IN RESPONSE TO THE QUESTION, HAVE WE BEEN PERSONALLY TOUCHED BY SUICIDE AND I THINK YOUR COMMENTS, AND MANY OF US ON THIS SIDE OF THE ROOM AND I'M SURE ON THAT SIDE OF THE ROOM RAISED THEIR HAND. AND I THINK YOUR STORY SOUNDS SO FAMILIAR TO ME AND I ASSUME MANY OTHER PEOPLE IN TRYING TO COME TO TERMS AND UNDERSTAND THE EVENTS THAT HAPPENED. AND I THINK THIS MORNING REALLY PRESENTS THE CHALLENGE FOR ALL ALL OF US TO DO WHAT THE TITLE OF WORKSHOP IS, WHICH IS PREVENTION. SO WHAT I THOUGHT I'D DO IS JUST MAKE A FEW COMMENTS AND THEN OPEN UP TO THE PANEL AND TO THE AUDIENCE FOR QUESTIONS. BY WAY OF DISCLOSURE, MY BACKGROUND IS IN PSYCHIATRIC EPIDEMIOLOGY. SO I'LL BE COMMENTING A BIT FROM POPULATION PERSPECTIVE AND TOUCHING ON SOME OF THE THEMES THAT WERE PRESENTED EARLIER. SO, THE ULTIMATE GOAL HERE IS PREVENTION. WHAT DOES THAT MEAN TO PREVENT SOMETHING FROM HAPPENING IN THE FUTURE? THAT ENTAILS DOING ONE OF THE HARDEST THINGS THERE IS TO DO CERTAINLY IN MEDICINE BUT IN GENERAL, LIFE, WHICH IS TO PREDICT THE FUTURE. AND NOT ONLY THAT, WITH RESPECT TO SUICIDE, WE ARE TRYING TO PREDICT SOMETHING THAT IS RARE AND IT'S EXTREMELY DIFFICULT TO DO. AS AN ASIDE, IN POPULATION HEALTH, PREDICTION, ESPECIALLY IN THE CONTEXT OF PERSONALIZED MEDICINE TODAY, REQUIRES REALLY STRONG RISK FACTORS. AS AN EPIDEMIOLOGIST, WE TRADE IN RISK FACTORS ALL DAY LONG. WE TALK ABOUT ODDS RATIOS WHICH QUANTIFY, WHICH IS A MEASURE OF THE MAGNITUDE OF ASSOCIATION BETWEEN A RISK FACTOR AND DISEASE. AND RISK FACTORS, ODDS RATIOS WE TYPICALLY SEE ON A DAY-TO-DAY BASIS. IF WE GET ONE AT 2 1/2 OR 3, WE WRITE HOME ABOUT THAT AND IT'S A GREAT DAY. BUT DR. BRENT MENTIONED ONE OF THE STRONGEST RISK FACTORS FOR SUICIDE STUDIES SEVERAL DECADES AGO ARE FIREARMS. I HAVE THOSE RESULTS. AND I JUST WANT TO SHARE WITH YOU THE ODDS RATIO FOR SUICIDE IF THERE IS A FIREARM IN THE HOUSEHOLD, AND THIS IS DR. BRENT'S STUDY FROM 1993 AND OTHER SUBSEQUENT STUDIES FROM THE EARLY TWO THOUSANDS. ODDS RATIO FOR SUICIDE IF THERE IS FIREARM IN THE HOUSEHOLD IS 32. DR. BRENT'S STUDY SHOWS IN 2000 STUDY BY KONG, IT WAS 16 FOR MALES 25 FOR FEMALES AND IN A SIMILAR STUDY BY WEAVE IN 2003, IT WAS 17. THESE ARE INCREDIBLY STRONG. THESE ARE ODDS RATIOS WE DON'T SEE. AND IT'S STRIKING THAT FOR SUICIDE, WHICH IS ONE OF THE HARDEST THINGS TO PREDICT, WE HAVE A RISK FACTOR WHICH HAS SUCH A STRONG PREDICTIVE ASSOCIATION. SO, THAT GETS TO POINT NUMBER 2, WHICH IS WHAT DO WE MEAN BY RISK? AND THERE IS A VERY WELL-KNOWN PAPER THAT CAME WITHOUT I WAS IN GRADUATE SCHOOL BY A STATISTICIAN AND PSYCHIATRIST, THE TITLE OF WHICH IS COMING TO TERMS WITH THE TERMS OF RISK. AND I THINK WE ARE STILL GRAPPLING WITH MANY OF THE CONCEPTS RAISED IN THAT PAPER ABOUT WHAT IS A RISK? AND WHEN WE THINK ABOUT RISK, IT'S THE PROBABILITY OF AN EVENT OVER A SPECIFIC PERIOD OF TIME. AND OUR FOCUS THIS MORNING HAS BEEN ON IMMINENT RISK. RISK AVERT. WHAT DO WE MEAN BY THAT? BECAUSE BY IMMINENT RISK, WE MEAN THERE ARE TWO EMBEDDED CONCEPTS. A LEVEL OF RISK, LOW, MEDIUM OR HIGH AND OVER WHAT PERIOD OF TIME? SO WE MIGHT CONSIDER A LOW RISK OVER A VERY SHORT PERIOD OF TIME, DIFFERENTLY FROM A HIGH RISK OVER A VERY LONG PERIOD OF TIME. I THINK THE STATEMENT THAT YOU MADE AT THE BEGINNING ABOUT CLINICIAN DOESN'T CARE IF A PATIENT IS AT RISK YEARS FROM NOW, REFLECTS THE CURRENT PRACTICAL REALITY IN THE STATE OF THE SCIENCE ABOUT THE IMPORTANT FROM A PREVENTION PERSPECTIVE OF INTERVENING IN ACUTE SITUATIONS OF ACUTE NEED. BUT ALSO OUR INABILITY TO DO LONG TERM PREDICTION AND TO CHANGE THE UNDERLYING MECHANISMS MECHANISMS. THE PROBABILITY THAT A SMOKER WILL DEVELOP LUNG CANCER ON A LIFETIME BASIS IS 10-15%. YET WE STILL DO VERY INTENSE INTERVENTIONS TO TRY TO AVOID THAT RISK. I DON'T THINK WE ARE THERE YET IN TERMS OF TYPES OF INTERVENTIONS FOR SUICIDE. HOPEFULLY THAT IS WHERE WE WILL GET TO. SO THE LAST SET OF COMMENTS I'D LIKE TO MAKE AND OPEN THAT UP FOR DISCUSSION ARE TO THINK ABOUT WHAT THE RISK FACTORS ARE. AND SEVERAL OF OUR PRESENTERS THIS MORNING TALKED ABOUT WHAT THE MOST COMMON NEWLY-ESTABLISHED RISK FACTORS ARE FOR SUICIDE. SO WHAT IS A RISK FACTOR? AS KRAMER WROTE, IT'S SNAG PREDICTS THE PROBABILITY OF AN EVENT. FUTURE OCCURRENCE. BUT AS WAS MENTIONED, IT DOESN'T MEAN THAT IT IS A CAUSAL FACTOR. WE NEED TO GET AT THE CAUSAL FACTOR IN ORDER TO INTERVENE AND HAVE EVIDENCE FOR INTERVENTION. THAT DOESN'T MEAN TO SAY THE RISK FACTOR THEMSELVES AREN'T USEFUL BECAUSE IT HELPS US IDENTIFY GROUPS AT HIGH RISK. BUT DIFFERENTIATING THE RISK FACTORS IS KEY FOR KNOWING WHAT TO INTERVENE ON WE SAW THE PIQUE THAT RAISES THE QUESTION AND THIS RISK, THE UNDERLYING DIE ATH SIS EMERGE DURING ADOLESCENCE OR CAN WE IDENTIFY EARLIER ON? AND I THINK ABOUT PREVENTION? MORE UPSTREAM AND UNDER THE ICEBERG WE SAW EARLIER. ULTIMATELY, WE NEED TO DO EVERYTHING THAT WE CAN TO REVERSE AND -- YES? YES. SURE. WE WANT TO DO EVERYTHING WE CAN TO HALT AND TURN BACK THE POPULATION LEVEL TRENDS THAT WE SAW EARLIER AND IN ORDER TO DO THAT, THAT WILL REQUIRE NEW INFORMATION ON THE ETIOLOGY OF SUICIDE, WHICH WILL COME FROM SOME OF THE NEUROBIOLOGICAL STUDIES, STUDIES WE ARE SEEING NOW ON BIOMARKERS AND FROM A BETTER UNDERSTANDING AND LASTLY, ATTENTION FROM MY PERSPECTIVE ON UNIVERSAL INTERVENTIONS VERSUS HIGH-RISK. GENERAL OR POPULATION-BASED INTERVENTIONS AS CONTRASTED WITH HIGH-RISK APPROACHES. THIS WAS THE CLASSIC CONUNDRUM THAT JEFFREY ROSE WROTE ABOUT IN HIS PIONEERING WORK ON POP LADIES-BATION APPROACHES VERSUS HIGH RISK. THIS IS NOT AN EITHER-OR BUT BOTH ARE REQUIRED WE NEED TO DEVELOP BETTER INTERVENTIONS IN ACUTE RISK PHASE. I WANT TO ETCH SIZE YOUR POINTS ABOUT CONNECTION AND THE IDEA THAT SUICIDE TELLS US SOMETHING ABOUT THE STATE OF SOCIETY ALSO NOT SOMETHING NEW BUT THE FIRST BOOK I READ ABOUT SUICIDE WAS THE BOOK ON SUICIDE IN COLLEGE WHEN I STARTED TO THINK ABOUT THESE ISSUES. AND HOW SUICIDE IS REFLECTIVE OF BROADER SOCIETAL FACTORS THAT SHAPE HUMAN RELATIONSHIPS I WANT TO OPEN TO THE PANEL. DR. ARGYRIS STRINGARIS IF YOU WANT TO MAKE ANY COMMENTS. AND OPEN IT UP TO THE AUDIENCE. LET ME ASK DO ANY OF THE PANEL MEMBERS WANT TO MAKE ANY COMMENTS? >> I THINK THE OPPORTUNITY TO THINK ABOUT THIS IN TERMS OF POPULATION HEALTH IS REALLY IMPORTANT. PARTICULARLY WHEN YOU KNOW THE PAYOFF FOR INTERVENTIONS IS 10-20 YEARS AND THE ELECTION CYCLE IS EVERY TWO YEARS. IT'S HARD TO GET COMMITMENT TO LONG TERM YIELD BUT THE WASHINGTON STATE PUBLIC POLICY INSTITUTE IS REALLY COOL WEBSITE WEBSITE. THE STATE OF WASHINGTON PAYS FOR THE INSTITUTE TO DO COST BENEFIT ANALYSIS ON DIFFERENT PREVENTION PROGRAMS AND SO THERE IS SOMETHING CALLED THE GOOD BEHAVIOR GAME, WHICH IS AN INTERVENTION THAT IS DONE WITH FIRST GRADERS TO ENCOURAGE PRO-SOCIAL BEHAVIOR AND DECREASED AGGRESSION. IN 30-YEAR FOLLOW-UP, THEY CUT THE RATE OF SUICIDE ATTEMPTS IN HALF. AND THAT YOU GET 65 DOLLARS BACK FOR EVERY DOLLAR THAT YOU INVEST. BUT IT TAKES YEARS TO GET THAT MONEY BACK. AND SO, THERE IS PREVENTION OF MALL TREATMENT. THERE IS A LOT OF THINGS THAT WE COULD BE INVESTING IN THAT WILL -- THEY WON'T -- WE WERE TALKING ABOUT IMMINENT RISK. IF YOU WANT TO ELIMINATE 25% OF THE SUFFERING IN MENTAL HEALTH SUFFERING, ELIMINATE MALL TREATMENT, AND SO I GUESS WHAT I WOULD SAY IS THAT FROM A POLICY PERSPECTIVE, IF WE COULD PUSH OUR LEADERS MORE IN THAT DIRECTION, I THINK WE COULD HAVE MORE OF AN IMPACT OF THINGS THAT ARE ALREADY PROVEN. >> ANY OF THE OTHER PANELISTS? SO WE HAVE QUESTIONS. THERE IS A MICROPHONE. AND WE'LL PASS THE MINING PHONE UP TO THE AUDIENCE AFTER YOU ASK YOUR QUESTION. >> MY QUESTION IS THAT DO YOU THINK THE WAY MEDIA PRESENTS SUICIDE IN SHOWS THAT TARGET ADOLESCENTS, SUCH AS 15 REASONS WHY, GLAMORIZE SUICIDE AND DOING THIS HAS IMPACT ON THE INCREASE IN SUICIDE RATE IN YOUNG ADULTS AND AS A FOLLOW-UP, WHAT ARE SOME GUIDELINES YOU WOULD SUGGEST TO HOLLYWOOD AND THE MEDIA ON HOW TO PRESENT SUICIDE, ESPECIALLY IN THE SHOWS THAT TARGET ADOLESCENTS? >> I'LL JUST REPEAT THE QUESTION TO MAKE SURE I GOT IT. THE ISSUE OF 13 REASONS WHY AND THE POSSIBLE DILLTORIOUS EFFECTS AND WHAT GUIDELINES SHOULD PEOPLE FOLLOW, HOLLYWOOD. SO THERE ARE A NUMBER OF THINGS ABOUT THE SHOW THAT I HAVEN'T WATCHED IT, BUT I READ ABOUT IT. AND I TEND TO AVOID ANY KIND OF ENTERTAINMENT THAT HAS TO DO WITH MENTAL HEALTH. ANYWAY, THERE ARE A NUMBER OF THINGS ABOUT THE SHOW THAT ARE DISCONCERTING. IT SHOWS A KID -- FIRST OF ALL, IT SHOWS A KID IN A VOICE OVER AFTER THE SUICIDE HAS TAKEN PLACE, WHICH SORT OF GIVES YOU THE IDEA THAT YOU CAN HAVE AN INFLUENCE ON PEOPLE AFTER YOU'RE GONE, WHICH I DON'T KNOW IF THERE IS ANY EMPIRICAL EVIDENCE FOR THAT. AND THEY SHOW EVERYBODY AS UNSYMPATHETIC AND UNHELPFUL, WHICH GIVES YOU THE IDEA THAT THERE IS NO USE IN TRYING TO SEEK OUT HELP BECAUSE ADULTS AREN'T GOING TO UNDERSTAND. AND SO, THERE ARE A LOT OF THINGS NOT TO LIKE ABOUT IT AND I THINK THERE HAVE BEEN SOME STUDIES HAVE SHOWN UPNICK SUICIDE ATTEMPTS. I REVIEWED AN ARTICLE THAT IS NOW IN PRESS THAT WAS DONE IN BRAZIL. I PROBABLY CAN'T SEE TOO MUCH ABOUT IT, BUT IT WAS SURPRISING BUT THEY FOUND A LOT OF POSITIVE EFFECTS FROM THE SHOW. SO, FROM A THEORETICAL POINT OF VIEW, I THINK IT IS HORRIBLE. BUT WE SOMETIMES DON'T KNOW. THE GUIDELINES GENERALLY ARE THAT YOU DON'T GLAMORIZE. YOU DON'T PRESENT THESE KIND OF PAYOFFS FOR SUICIDE THAT AREN'T THERE. AND THAT YOU TREAT IT MORE CLINICALLY. HOWEVER, YOU'RE BEGINNING TO DIMINISH THE ENTERTAINMENT VALUE AS YOU DO THAT. SO THERE IS KIND OF A CONFLICT OF INTEREST THERE. THOSE ARE THE GENERAL GUIDELINES GUIDELINES. >> SO, THERE WAS AN UPTICK IN EMERGENCY DEPARTMENT VISITS ALL OVER THE COUNTRY AT THE TIME FOR SUICIDAL IDEATION AT THE TIME OF THAT SHOWING. AND THERE ABSOLUTELY COULD BE A SILVER LINING THAT A THOUGHT -- I DID SEE THE SHOW. AND THEY ABSOLUTELY DEPICTED ADULTS AS COMPLETELY USELESS. SO EVERYTHING WE SAY TO KIDS IS ALWAYS, FIND A TRUSTED ADULT. LIKE THAT IS THE MANTRA. AND THERE WAS NO TRUSTED ADULT IN THAT SERIES. THEY ALSO, I THINK, WHAT WASN'T RESPONSIBLE WAS THERE WAS NO HOTLINE NUMBER FLASHED IN THE BEGINNING OR THE END. THERE WAS NO CRISIS TEXT LINE. THEY COULD HAVE DONE THINGS THAT WERE REALLY HELPFUL. THE SILVER LINING WAS, IT FORCED CONVERSATIONS ALL OVER IN SCHOOLS ALL OVER THE COUNTRY. SCHOOLS STARTED SENDING COMMUNICATIONS TO PARENTS AND CONVERSATIONS STARTED. SO IN THAT WAY, I THINK THAT COULD HAVE BEEN A SILVER LINING. >> CAN I MAKE A REMARK FIRST OF ALL? A LITTLE HISTORICAL ANECDOTE, THE FIRST TIME THERE HAS BEEN A SEMI--DOCUMENTED INCREASE IN SUICIDE AS A RESULT OF A SERIES OF THE TIME, IS OF COURSE AFTER [ INAUDIBLE ] SUFFERINGS OF A YOUNG VETTA. AT THE TIME -- DOES EVERYONE KNOW ABOUT THIS? SO THERE WAS A SUICIDE WAVE AFTER A THE AUTHOR PUBLISHED THIS BOOK, WHICH IS A ROMANTIC DEPICTION OF LOVE, UNREQUITED LOVE AND SUBSEQUENT SUICIDE. SO THE FIRST INDICATION WE HAD AND THEREAFTER THERE HAVE BEEN STUDIES ABOUT THIS. BUT IT WAS QUITE INTERESTING. THE ROMANTIC DEPICTION OF A YOUNG MAN WHO EVENTUALLY KILLS HIMSELF. RELATED TO THAT, SOME CLINICIANS WILL ARGUE THAT YOU HAVE YOUNG PEOPLE IN WHOM -- AND I WILL USE THE TERM THAT IS BEING USED, VERY CONSCIOUSLY, IN WHOM SUICIDAL BEHAVIORS ARE BEHAVIORS TO ILLICIT ATTENTION FOR SOME SECONDARY GAIN AND THAT THERE IS THE ISSUE OF REWARDING SUCH BEHAVIORS WITH TOO MUCH ATTENTION. SO THE CLINICIANS FIND THEMSELVES VERY OFTEN IN SITUATIONS WHERE THEY DON'T QUITE KNOW HOW TO HANDLE. OF COURSE YOU WANT TO BE VERY RESPONSIVE TO ALL THIS. BUT HOW CAN SOMEONE BE RESPONSIVE CLINICALLY WITHOUT FEEDING, REINFORCING, BEHAVIORS THAT ARE CLEARLY MALADAPTIVE IN WHICH THE HOME ENVIRONMENT CERTAINLY, BUT AULSO IN CERTAIN CLINICAL ENVIRONMENTS, ARE USED AND CONSCIOUSLY PROBABLY, TO TRIGGER CERTAIN RESPONSES? >> I CAN TALK ABOUT DBT BUT JUST ALSO TO ALLUDE TO THE IMPORTANCE OF THEN HAVING MULTIPLE VOICES IN THE CONVERSATION. I WAS ON MANY E-MAIL CHAINS RELATED TO THE 13 REASONS WHY AND ONE OF THE FOCUS WAS, WHO IS THE CLINICIAN INVOLVED WITH THE CONSULTATION? WHO WAS THE PERSON WITH LIVED EXPERIENCE? I THINK MORE AND MORE, THAT IS HAPPENING FROM RESEARCH, OBVIOUSLY WE HAVE SOMEBODY WITH LIVED EXPERIENCE THAT JUST GAVE A VERY MOVING PRESENTATION, BUT I THINK MORE AND MORE, WE ARE INTEGRATING THESE INDIVIDUALS INTO RESEARCH AND IT SHOULD BE ALSO INTO GREATED IF IT YOU'RE TRYING TO CREATE ART OR ENTERTAINMENT RELATED TO THIS. I DON'T THINK WE CAN IGNORE EITHER ASPECT FROM A RESEARCH PERSPECTIVE OR FROM A COMMERCIAL PERSPECTIVE. WE REALLY SHOULD BE INVOLVING PEOPLE WHO HAVE DIRECT EXPERIENCE WITH THIS. AND I THINK FROM THAT REALLY WILL COME MORE RESPONSIBLE PRODUCTION. >> SO, WHEN THE SHOW CAME OUT, I DID WATCH IT. AND I KEPT DOING INTERVIEW AFTER INTERVIEW ON TELEVISION ABOUT IT, BECAUSE IT WAS THE BIG SUBJECT. AND I DECIDED THAT FOR MY BLOG, I WOULD ASK A TEENAGER TO, WHO SUFFERED FROM DEPRESSION, TO GIVE US HER PERSPECTIVE. SO I LET HER OFFER HER OPINION ON IT AND IT WAS JUST REALLY INTERESTING. SHE SAID THE SHOW WAS A TRIGGER FOR HER. SO SHE COULDN'T WATCH IT. SO I THINK AT THE VERY LEAST, HAVING THE PHONE NUMBERS AND A TRIGGER WARNING TO PEOPLE WHO ARE VULNERABLE. AND BECAUSE IT DOES KIND OF GLORIFY IT. AN IRRATIONAL STATE OF MIND AND SOMEBODY PLANS OUT THIRTEEN TAPES -- THAT IS JUST NOT REALISTIC. BUT THAT IS HOLLYWOOD FOR YOU. AND WE ARE NOT GOING TO BE ABLE TO CONTROL THEIR CONVERSATION. BUT WHAT WE CAN DO IS SAY, OKAY, IF YOU WILL HAVE IT, PLEASE PUT THESE CONTROLS IN PLACE, AT LEAST. >> TO YOUR ATTENTION QUESTION, I THINK THIS IS THE REALLY TRICKY PART BECAUSE THERE IS ALL DIFFERENT KINDS OF SUICIDAL PRESENTATIONS. AND SO THERE IS THE BOY WHO CRIED WOLF SUICIDAL PRESENTATION. BUT YOU HAVE TO PAY ATTENTION EVERY SINGLE TIME BECAUSE YOU NEVER KNOW WHEN IT WILL BE SERIOUS AND WHEN IT IS NOT. AS FAR AS THE ATTENTION GOES, I THINK YOU ALWAYS HAVE TO, ESPECIALLY WITH A KID, I THINK YOU ALWAYS HAVE TO GIVE IT ATTENTION BECAUSE I THINK THIS IS TRICKY TOO -- BUT IF THEY ARE SEEKING SOMETHING, YOU CAN TAKE IT SERIOUSLY AND THEN TALK ABOUT THESE SECONDARY GAINS THAT MIGHT BE COMING UP. BUT I THINK IT IS REALLY A TIGHTROPE TO WALK. >> IN SOME THERAPEUTIC COMMUNITIES, WITH SOME RESULTS, PEOPLE WITH BORDERLINE PERSONALLY DISORDER, PEOPLE ARE -- [ LOW AUDIO ] SO THERE ARE THERAPEUTIC COMMUNITIES WHERE INSTEAD OF PREVENTING THE ACTUAL SELF HARM, PEOPLE ARE BEING TOLD, IF YOU WANT TO DO THIS -- APPARENTLY WITH RESULTS. SO THERE IS A TENSION BETWEEN PEOPLE DO AND WHAT FROM A BEHAVIORAL PERSPECTIVE PEOPLE WOULD SAY IS THE RIGHT THING TO DO AT THAT POINT IN SOMEONE WHO HABITUALLY SELF HARMS. I'M NOT ADVOCATING ANY OF THAT. IT'S JUST TO BE CLEAR ABOUT, IT'S A DILEMMA THAT MANY CLINICIANS COME UP WITH AND HAVE DIFFICULTIES, PARTICULARLY IN SETTINGS WHERE THE SELF HARM OCCURS IN PEOPLE WHO HAVE WHAT WOULD BE CALLED RIGHT LEOR WRONGLY, A PERSONALITY DISORDER. >> I DON'T THINK WE HAVE TIME TO GET INTO EXTENSIVE DISCUSSION OF THE TREATMENT, BUT I WANT TO ALLUDE THAT WE DID TALK ABOUT DIALECT CALL BEHAVIORAL THERAPY AND WHY IT TAKES SO LONG TO HAVE AN INSPECT AND IT DOES TAKE AT LEAST 6 MONTHS IF NOT A YEAR BECAUSE YOU'RE HAVING TO REINFORCE DIFFERENT BEHAVIORS. DOES ANYBODY DO DBT HERE? THANK YOU FOR DOING THAT AMAZING WORK. SO YOU ARE ON CALL POTENTIALLY 24-7 BUT THE IDEA IS THAT THEY ARE SUPPOSED TO CALL YOU BEFORE THEY ENGAGE IN THE BEHAVIOR. SO THAT YOU'RE NOT REINFORCING THE BEHAVIOR. YOU'RE REINFORCING THEM REACHING OUT AND DOING THE COPING STRATEGIES. AND THAT IS JUST ONE ASPECT OF A VERY COMPLICATED TREATMENT BUT I THINK REALLY SPEAKS TO THE IMPORTANCE OF THINKING THROUGH VERY CAREFULLY HOW WE MAKE SURE WE DON'T REINFORCE BEHAVIOR INADVERTENTLY. >> THANK YOU. I THINK THAT DR. GOLDSTEIN HAS BEEN WAITING APPARENTLY FOR HIS QUESTION AS WE ARE ALL. >> I'M GOING TO PROPOSE TO THE PANEL A DISHONEST QUESTION. THAT IS, AROSE FROM A WELL-MEANING NEED WE HAVE. WE HEARD TODAY DIFFERENT THINGS RELATED WITH SLEEP. FIRST IT IS VERY INTERESTING THAT EARLY MORNING AWAKENING 4 A.M., IS ONE OF THE MAIN STAY SYMPTOMS OF DEPRESSION, AT LEAST HISTORICALLY. THE SECOND IS THAT WE ARE USED TO WAKING UP PATIENTS AT 4 OR 5 TO RELIEF DEPRESSION, AT LEAST IN THE SHORT-TERM. BY ABOLISHING DREAMING. THE THIRD IS THAT IT WAS PRESENTED TODAY THAT THE MOST DANGEROUS TIME IS WITHIN THE WEEK TO 10 DAYS AFTER DISCHARGE. SO WE ARE ALREADY DONE WITH THE SCREENING AND IDENTIFIED THE PEOPLE THAT HAVE HAD BEHAVIORS RELATED WITH SUICIDE. SO, WE PUT THEM IN THE HOSPITAL FOR 3-4 DAYS, WE LOAD THEM WITH WHATEVER MEDICINE WE WANT TO LOAD THEM. WE KNOW IT'S NOT GOING TO ACT AND THEN 10-14 DAYS OR 10-14 WEEKS. DOESN'T MATTER BUT THE FIRST 10 DAYS IT'S NOT GOING TO BE THERE. AND THEN WE GIVE THEM KETAMINE AND THE ONE THING THAT KETAMINE DOES IS PUT THEM TO SLEEP AT 4:00. SO THE DISHONEST QUESTION IS, SHOULD WE PUT THIS PATIENT TO SLEEP BY ANY MEANS NECESSARY IN THE FIRST WEEK TO 10 DAYS AFTER >> I MEAN, THERE IS SO MUCH TO UNWRAP THERE. IN TERMS OF WHAT WE KNOW IN TERMS OF TOTAL SLEEP DEPRIVATION, WHICH YOU'RE ALLUDING TO WITH THE 36-40 HOURS OF SLEEP DEPRIVATION ACTUALLY HAVE BRIEF ANTI-DEPRESSANT EFFECTS THAT ARE VERY SHORT-LIVED. AND THERE IS SOME THOUGHT THAT IT ACTUALLY WORKS IN A VERY SIMILAR MECHANISM AS KETAMINE. WE DON'T KNOW AND WE ARE TRYING TO SLEEP DEPRIVE PEOPLE AND THEN GIVE THEM KETAMINE TO TRY TO UNDERSTAND. BUT IT IS THE PARADOXICAL REACTION THAT IN SOME WAYS SLEEP DEPRIVATION CAN HELP SHORT-TERM BUT OVER ALL, WE KNOW IT'S NOT A GREAT THING LONG TERM. I CAN'T ANSWER ABOUT BY ANY MEANS NECESSARY GETTING PEOPLE TO SLEEP. I DO KNOW THAT WORKING WITH PSYCHIATRIC PATIENTS, A LOT OF TIMES THEY ARE REALLY AGITATED AND HAVEN'T SLEPT IN A WHILE AND THEY REALLY FIND THE PSYCHIATRIC INPATIENT UNIT AS A PLACE TO SLEEP, GET AWAY FROM THEIR PROBLEMS FOR A LITTLE WHILE. AND I DON'T THINK WE SHOULD IGNORE THE POTENTIAL PSYCHOSOCIAL EFFECTS OF THAT. AND JUST IN GENERAL, WHAT I'M HOPING TO DO IN MY OWN RESEARCH IS TRYING TO UNDERSTAND ABOUT KETAMINE AND COULD WE COMBINE THAT WITH A COGNITIVE THERAPY FOR SLEEP AND REALLY START THE GOOD WORK FIRST AND THEN SORT OF BUILD ON THAT SO THAT WHEN THEY DO LEAVE THE PIN PATIENT UNIT, THEY CAN SLEEP. >> [ OFF MICROPHONE ] >> I WILL SAY ONE THING AND THEN LET DR. BRENT ANSWER ALL YOUR QUESTIONS. [ LAUGHS ] I WILL SAY THAT THERE ARE PEOPLE WHO ARE EVALUATING THAT. I THINK OUT IN CALIFORNIA, I THINK IT'S UC IRVINE, THERE ARE STUDIES LOOKING AT CERTAIN MEDICATIONS. I DON'T KNOW WHAT THEY ARE. THEY ARE LOOKING AT THE SPECIFIC SUICIDE QUESTION AS WELL AS CBT FOR SUICIDE AS WELL IF YOU INTERVENE DIRECTLY. BUT I THINK WE WOULD HAVE TO THINK VERY CAREFULLY AND THEN SLEEP MEDICATIONS AS POTENTIAL DEPENDENCE. THERE IS A NUMBER OF QUESTIONS THAT ARISE. >> THE SLEEP MEDICATIONS ARE PRETTY DANGEROUS. AFTER SEVERAL YEARS OF NOT FINDING ANY ANSWERS TO MY SON, WE DID GET TO A POINT WHERE WE TRIED MEDICATION. THE TROUBLE IS, WITH CERTAIN AGE LIKE ADOLESCENTS, THEY MIX THAT WITH ALCOHOL AND IN ONE INCIDENT, MY SON MIXED AMBIAN AND IT WASN'T DOING THE TRICK. SO HE DECIDED A LITTLE VODKA WOULD GIVE IT SOME HELP. AND SOMEBODY WALKS UP THE DRIVEWAY IN OUR BEACH VACATION AS WE ARE PACKING UP AND THEY SHOWED ME A PICTURE OF MY SON IN A CONVENIENCE STORE AND THEY SAID THAT HE BROKE IN THAT NIGHT. CHARLES DIDN'T EVEN REMEMBER IT. IT MADE HIM COMPLETE NUT CASE. AND HE DID THAT ONE OTHER TIME. AND I GOT TO OBSERVE IT THAT TIME AND HE WENT OUT ON THE ROOF AT 18 DEGREES NAKED AND PEDE ON THE ROOF. SO, THAT IS THE TROUBLE WITH SOME OF THESE SLEEP MEDICATIONS. IT MAY BE -- IF THEY ARE TAKING AS IT I DONE FOR DEPRESSION, THAT HAS THAT EFFECT SO IT MAY BE THAT THE PSYCHIATRIST CAN SWITCH A MEDICATION TO ONE WITH A MORE SEDATIVE, IF THAT IN FACT TURNS OUT TO BE SOMETHING TO DO, WHICH I'M NOT QUALIFIED TO SPEAK ON. >> THE PART I WANT TO RESPOND TO IS THE, BY ANY MEANS NECESSARY. I SAY YOU WANT TO AVOID THOSE HYPNOTICS. THE PHARMACOEPIDEMIOLOGIC DATA SUGGESTS THEY ARE BAD FOR YOU. AND THAT IT IS ASSOCIATED WITH SUICIDE. ALTHOUGH IT IS HARD TO TELL IF IT IS WHO THEY ARE TREATING. BUT WHAT WE DO KNOW IS THAT THE COGNITIVE THERAPY FOR INSOMNIA DOESN'T HAVE THOSE SIDE EFFECTS. AND IT HAS BEEN SHOWN TO DROP SUICIDAL IDEATION PRETTY RAPIDLY. SO I THINK THE IDEA THAT SOME KIND OF RAPID ANTI-DEPRESSANT, PLUS PSYCHOSOCIAL INTERVENTION TO REDUCE INSOMNIA, I THINK IS INDICATED. I HAVE TO SAY THAT IF YOU WERE GOING TO CHANGE ONE THING IN THE WAY THAT PHYSICIANS ARE TRAINED, IT WOULD BE TO TRAIN THEM TO DEAL WITH SLEEP BETTER. I THINK THEY WOULD HAVE A HUGE PUBLIC HEALTH. AND THE AFFECT IS, EVEN MOST PSYCHIATRISTS AREN'T THAT WELL-TRAINED ON HOW TO DEAL WITH SLEEP PROBLEMS. AND WE TEND TO THINK, OR TENDED TO THINK, GEE, IF I TREAT THE DEPRESSION, EVERYTHING WILL BE FINE. AND IF THESE KIDS ARE STILL NOT SLEEPING WELL, THEY ARE IMPULSIVE -- I MEAN MORE THAN I CAN DESCRIBE CLINICALLY. I THINK THE IDEA IS THE PSYCHOSOCIAL INTERVENTIONS ARE BRIEF. THEY ARE HARMLESS IN THE SENSE AND I THINK WE NEED TO USE IT MUCH MORE FREQUENTLY. >> THANK YOU. DR. GILMAN DID YOU HAVE A COMMENT YOU WANTED TO MAKE? >> NO, I WANTED TO TURN IT BACK TO THE AUDIENCE. >> THERE IS A QUESTION HERE. >> THANK YOU. THANK YOU ALL FOR YOUR TALKS TODAY. THEY WERE REALLY INFORMATIVE. I DID A LOT OF SCHOOL-BASED MENTAL HEALTH. SO UNIVERSALLY, WHAT KIND OF THOUGHTS OR RESEARCH ARE THERE ON LIKE EXPANDING SCREENINGS OR EVEN TEACHING EDUCATORS LIKE HOW DO YOU RESPOND TO KIDS? BECAUSE I KNOW I HAVE HEARD JUST OVERHEARD A LOT OF TEACHERS MAKING GENERAL COMMENTS LIKE, YOU'LL BE FINE. DON'T WORRY ABOUT IT. NOT NECESSARILY DIRECTLY TO A SUICIDE IDEATION BUT KIDS BEING SAD OR UNCOMFORTABLE FEELINGS IN GENERAL. SO, JUST THOUGHTS ON EXPANDING TO -- TEACHERS SEE THESE KIDS EVERY DAY. THEY REALLY KNOW THEM WELL. WHAT KIND OF EDUCATION IS THERE FOR THEM TO KNOW WHAT QUESTIONS TO ASK, HOW TO RESPOND AND THEN HOW TO SEND THEM TO THE RIGHT PEOPLE? >> SO, THERE ARE PROGRAMS THAT GO INTO SCHOOLS, THINGS LIKE SIGNS OF SUICIDE, JOHN ACKERMAN AND JEFF BRIDGE, I KNOW ARE WORKING AT OSU ON PROGRAMS LIKE THAT. AND I THINK AS FAR AS BLANKET SCREENING IN SCHOOLS, I THINK THAT HAS BEEN DONE IN THE PAST WITHOUT SUCCESS BECAUSE THERE IS NOT ENOUGH RESOURCES TO HANDLE AND INTERPRET THE POSITIVE SCREENS. BUT DEFINITELY PUTTING SCREENING TOOLS IN SCHOOL NURSING OFFICES LIKE THE KIDS WHO KEEP SHOWING UP IN THE SCHOOL NURSE OFFICE. WE HAVE SOME DATA THAT WE HAVEN'T LOOKED AT YET FROM AMSTERDAM, ACTUALLY, WHERE THEY WERE USING THE ASQ IN THE PUBLIC SCHOOL SYSTEM SO WE ARE GOING TO LOOK AT THAT. BUT I KNOW THERE IS PROGRAMS THAT SPECIFICALLY TARGET EVERYTHING YOU JUST ASKED ABOUT, GOING IN, TEACHING THE TEACHERS, THE GUIDANCE COUNCILORS, THE SCHOOL NURSE, THE COACHES, THE PARENTS, THE KIDS. HOW TO DO PEER TO PEER RECOGNITION. I THINK THAT IS ALL REALLY IMPORTANT. >> SO THERE WAS A RANDOMIZED CLINICAL TRIAL LED BY WASESSER MAN IN EUROPE, AND THEY COMPARED QPR, WHICH IS A GATEKEEPER TRAINING, SCREENING AND REFERRAL, SOMETHING CALLED YAMS, LIKE THE SIGNS OF SUICIDE, IT'S A CURRICULUM. AND THEN A CONTROL CONDITION. AND IT INVOLVED OVER 11,000 KIDS. AND THE CURRICULUM REDUCED THE SUICIDE ATTEMPT RATE BY HALF IN THE 12-MONTH FOLLOW-UP. THE OTHERS DIDN'T HAVE AN AFFECT. AND THE QPR IS A MIXED BAG BUT THE OTHER RCT THAT INVOLVED IT, IT IMPROVED PEOPLE'S SENSE OF THEIR EFFICACY TO TALK WITH KIDS BUT IT DIDN'T ACTUALLY CHANGE ANY IDENTIFICATION BECAUSE A HIGH PROPORTION OF KIDS HAD A NEGATIVE ATTITUDE ABOUT SEEKING HELP AND SO THE CURRICULUM INTERVENTIONS WITH THE KIDS SEEKS TO DO THAT. AND SO, THAT IS PROBABLY ONE ESSENTIAL INGREDIENT THAT YOU NEED TO HAVE IN A SCHOOL-BASED SETTING. >> THANK YOU. THANK YOU VERY MUCH. I'M SAD TO SAY IT IS 12:30. AND THAT WE HAVE COME TO AN END. I WOULD LIKE TO THANK YOU ALL FOR YOUR ATTENTION AT THIS WORKSHOP. I WOULD LIKE TO THANK THE SPEAKERS, EACH ONE INDIVIDUALLY. IT WAS REALLY WONDERFUL TO HAVE YOU HERE. THANK YOU VERY MUCH. [ APPLAUSE ] AND EVERYONE WHO HELPED TO ORGANIZE IT, THANK YOU VERY MUCH FOR THE MODERATION AS WELL. [ APPLAUSE ]