Minnesota's Suicide Prevention Plan

I have pointed out several times on this blog that a number of non-medical forces in the state of Minnesota have been successful in making a mediocre mental health system into one that is on the brink of becoming a travesty.  My curiosity was naturally piqued when I heard that we now had a suicide prevention plan released just in time for Suicide Prevention Week and Suicide Prevention Awareness month.  How is suicide prevention and awareness possible in a seriously deteriorating nonsystem of care?  Who are the people writing this report and what does it say?  As a person actively involved in suicide prevention every day of my career - I decided to read it and give my  impressions here.  The full text is available to anyone off the Minnesota Department of Health web site.

Scanning the document, it is very readable.  The main body is about 23 pages long with relatively large font and much if it is organized more like an outline rather than a document.  For reasons I will outline below - it could have been a lot briefer.  Task Force member are listed and it appears that none of them are psychiatrists.  Of the 19 listed Task Force members - one of them is a physician.  The stated goal of the work is:

"To reduce suicide in Minnesota by 10% in five years, 20% in ten years, ultimately working towards zero ....." (page 7)

That is certainly a laudable goal.  There are recent reviews and ongoing debates about whether suicide can be eliminated and a recent consensus statement says no (1).  Buried on page 19 is the statement "Encourage health care systems to implement the Zero Suicide Model.  There is a link provided to SAMHSA on this model and it is the product of non-experts.  Because of its promotion of managed care I do not consider SAMHSA to be a reliable source of information or expertise.  A review of what is available the Zero Suicide Model (4) illustrates that it is basically a management heavy model of what used to be considered standard psychiatric care before psychiatric care was disrupted by business interests with the usual EHR kowtowing.

 As far as reduced rates or total suicides in the state a useful question is whether or not the trends in suicide rates or total number of suicides is a real trend in Minnesota or it reflects expected variation.  The second important question is whether it is a population wide phenomenon or it reflects subpopulations that are impacting on the statewide rates.  The authors attempt to answer these questions by showing an increase in the rates of suicide from 8.9 per 100,000 (n=440) in 2000 to 12.2 per 100,000 (n=683) in 2013 - the last year of complete data for the report.  The ratio of men:women who died by suicide was 4:1.  The rate across the US was 12.6 - the Minnesota rate is slightly less than the national rate.  Among subgroups of the population the American Indian group had the highest rate at 17.2 per 100,000 (n=70) followed by White at 12 per 100,000 (n=2,941).  Black or African Americans had the lowest rate at 6.9 per 100,000 (n=104).  American Indian Youth (10-24) had the highest rate at 28.0 per 100,000 (n=30).  

A standard method to determine if death trends related to risk factors or illness are significant is joinpoint regression analysis developed by the National Cancer Institute to analyze trends in cancer deaths.  Since then it has been used by both the CDC and researchers (3) looking at trends in suicide rates.  I did not see the application of this kind of analysis to the rates over the 14 year period of time discussed in the article.  That does not mean it was not done, just not apparent.  At the minimum an analysis of longer term trends should be accomplished along with comparisons to other macro indicators like economic variables would be interesting as a basis for preventive recommendations.

The authors leap into their model called a social ecological model of suicide that was adapted from the World Health Organization.  A graphic is included in the statement.  The model appears to be generally applied - it has been widely adopted by the WHO and the CDC as a way to address suicide and violence but also colon cancer and a host of other medical problems.  It seems to be a modern equivalent of the old nature versus nurture or schizophrenigenic mother argument.   Cataloguing all of the perceived deficiencies in the environment is not the same thing as discovering the mechanism or cause of a specific problem in a specific person.  Obvious examples abound.  The vast majority of people who have had significant childhood adversity in the environment do not attempt or commit suicide.  That is a relevant question because a better approach may be studying those people and trying to figure out how they survived and either adapt to chronic levels of insomnia, anxiety, and depression or resolve it.  A consciousness based model may be the best approach.  The authors here seem to say that all of these social and economical factors need to be addressed and that is the approach that they are going to use to reduce the suicide rate.  Even using that approach they overstep the limits of the model and end up using a familiar political approach.

The political approach that I am referring to is to assume that somehow they know more about suicide than the professional trained to address it.  I speak only for psychiatrists, but this is a serious overstepping of authority.  I was board certified in Psychiatry in 1988 and it was well known at the time that if a candidate did not demonstrate that they could interview a person and assess their potential for suicide and aggression that they would fail the oral examination.  Psychiatrists have been focused on timely assessments of suicide and aggression for decades and it is incorporated into treatment guidelines at every level.  Those assessments are done very day by practically every psychiatrist working that day.  And yet the Minnesota Plan has the following guidance:


4.  Train professionals and community/cultural leaders to increase awareness of suicide and prevention efforts and mental health and wellbeing. (p.15)

3.  Train professionals and community/spiritual/cultural leaders to better understand how to talk to and encourage those at risk to access help. (p. 16)

Objective 2.2  Expect providers who interact with individuals at risk for suicide to routinely assess for access to lethal means.  (p. 17)

The authors here can make these statements because they are as non-specific as possible.  Psychiatrists are not mentioned at all in the document.  Neither are other mental health professionals.  Speaking only for psychiatrists again, we are practicing psychiatry with people who have the most severe forms of mental illness because we can assess and treat suicide and aggressive behavior.  We are certainly not looking to any state agency for training or accountability.  We are accountable to the people we treat and professional standards.  Furthermore we are acutely aware of the deficiencies in care in this state and input from psychiatrists would probably have been useful.  The tactic of pretending to tell professionals how to do their job and generally behave has been used by the managed care industry for years.  It is disappointing but not unexpected to see in in a document from a state who has been so friendly to that industry.

I can say without a doubt that most Minnesotans seeking acute care for a family member with suicidal thinking or suicidal behavior will be disappointed.  The severe rationing of psychiatric services has resulted in a lack of resources that would be comparable to any other medical emergency.  Families are frequently directed to hospital emergency departments where mental disorders are viewed creating congestion and inconvenience.  The social workers making the assessments there know that placement options are extremely limited.  The legislative response to their own rationing of psychiatric services has been to mandate that the patient be transferred to the nearest bed and that can be hundreds of miles away.  Once hospitalized most people realize the the inpatient units that were supposed to help them are grim and unsanitary places where they main goal is to convince the psychiatrist that they are no longer suicidal so that they can be discharged home. The family may find themselves in the uneasy position of monitoring their suicidal family member at home while they are trying to get them adequate treatment.  It is the logical progression of events to a government and insurance industry standard that dangerousness is the only reason a person can be admitted to a psychiatric unit these days.  Managed care reviewers call the physicians and nurses in charge looking for that day when the patient doesn't use the word suicidal.  At that point according to the insurance industry - the patient must be discharged.  They always have the excuse that it is up the the attending psychiatrist - but that has become a modern day joke.  The psychiatrist's own administration will insist that the patient be discharged or he/she might need to find another job.

How should it work?  Crisis care for suicidal or aggressive people should be based on an informed approach to the problem.  Risk factors (and protective factor) analysis is really an insufficient approach.  The approach that suicide is an epiphenomenon of other psychiatric disorders is also a limited approach.  There are certainly correlates of high suicide rates in most major psychiatric disorders - but how that person came to consider suicide is generally a unique pathway even in the case of most extreme mental illness.  First,  emergency department triage must go.  The only reason it exists is that there is inadequate funding for community mental health centers and their own crisis services.  The paradigm for this model is Dane County Mental Health Center in Madison, Wisconsin.  This has been one of the epicenters of community psychiatry in the US.  They have an active crisis service that runs all day long until 11PM.  They a have a walk in crisis center.  They are adequately staffed to avoid long waits and they do active crisis psychotherapy.  Second, inpatient psychiatry needs serious revision.  We can no longer accept the idea that a person in crisis sits on an inpatient unit until they say they are no longer suicidal.  Granted there are always social interventions along the way but a lot more needs to happen.  The units need to be clean, calm and comfortable places.  They need to provide an array of active services to treat both severe problems and address suicidal thinking.  They need to keep longitudinal data on the efficacy of their interventions.  They need to provide assessments and treatments for alcohol and substance use disorders.  There are many people who become suicidal only under the influence of alcohol or street drugs.  Most importantly, they need to admit people with severe problems even if they are not saying that they are suicidal at the time.  The reasons for that are twofold.  The majority of people with significant mental illnesses are not being treated.  If they cannot function this is a logical point to provide treatment and reduce the transition to suicide risk.  The other reason is that there are many severely ill people who clearly cannot function with their current level of distress.  They may have attempted suicide in the past.  Their psychiatrist knows they are high risk in the community, but currently there are no hospital or residential settings where these people can be admitted.

Read the document and make your own assessment.  The goals of modifying the social fabric in various communities in Minnesota seem unrealistic to me.  I think that this group and the parent document is overreaching - not just in the scope of what can be done for apparently very little funding but also the gross inconsistencies in government and business.  There are no bigger conflicts of interest these days than a government that seems to want to advertise that they are solving your problems when they are doing just the opposite and businesses that do the same.  A functional state department of health should use the usual public health tools with education being at the top.  Some more attainable and straightforward goals would be:                              

1.  Public education on suicide - especially the statistics the risk factors, and the fact that suicide is a treatable and resolvable condition.

2.  Means reduction - at a public health level these are some of the most successful interventions.  As an example, people need to know that just having a firearm in the home is the single most risk factor for suicide.  I get a letter every year telling me that I have to report the number of abortions that I performed last year and all of the abortion complications in Minnesota.  These same people have access to all of my professional information and know that I have never performed an abortion.  I have never investigated the origin of this letter but can only conclude it is a law written by an anti-abortion legislators hoping to shame physicians into not performing legal abortions.  Why isn't anyone using a more functional approach and sending conceal-carry permit holders a letter on suicide and gun possession.  Why isn't it being taught in public health classes in the schools?  Why doesn't everyone know that most deaths by firearms in this country are from suicide?

3.  Cultural permissiveness toward substance use - Minnesota has medical cannabis laws and an active group of recreational cannabis promoters.  There is a current nation wide movement to view psychedelics and hallucinogens as medications and psychotherapeutic agents.  There is very little discussion of the downside.  We are also in the midst of a highly lethal opioid epidemic.  As an addiction psychiatrist many of the people I talk with get to the point in their addiction that in their search for getting high - they don't care if they live or die.  They knew they were taking lethal or near lethal amounts and did not care.  In other cases, certain people with alcohol use problems will become suicidal only if they are intoxicated.  These correlates of substance use disorders and the suicidal lethality of substance use is practically unknown to most people.  It is not trendy or cool to push back against overwhelming pressure to get high - but that is exactly what needs to happen.  Stay sober and you reduce the chances of ever being suicidal.

4.  Don't depend on managed care companies to provide a reasonable system of care - The record is in and it is not a good one.  The idea that managers whoever they might be are going to teach or coerce professionals into providing better care for people with suicidal thinking when they have been working for three decades to do just the opposite seems absurd to me.  If the government wanted to do anything, it would be to provide functional oversight of these companies and their ongoing rationing of care.  Every state should have a physician review agency for treatments that is outside of the usual same company reviewers and insurance industry insiders placed on state regulatory boards.  That board should have the last word in what treatments are necessary.  Community mental health centers need to be refunded to provide adequate levels of care and they cannot be un like managed care companies.

These are a few of my thoughts today.  I might add another couple of bullet points as they come to mind.  This is a serious topic that deserves additional discussion and one I have been thinking about most of the time with varying levels of intensity for 30 years.                

George Dawson, MD, DFAPA



References:

1:  Shain B; COMMITTEE ON ADOLESCENCE. Suicide and Suicide Attempts in Adolescents. Pediatrics. 2016 Jul;138(1). pii: e20161420. doi: 10.1542/peds.2016-1420. PubMed PMID: 27354459.

2: 1: Sullivan EM, Annest JL, Simon TR, Luo F, Dahlberg LL; Centers for DiseaseControl and Prevention (CDC). Suicide trends among persons aged 10-24 years--United States, 1994-2012. MMWR Morb Mortal Wkly Rep. 2015 Mar 6;64(8):201-5. PubMed PMID: 25742379.

3: Puzo Q, Qin P, Mehlum L. Long-term trends of suicide by choice of method in Norway: a joinpoint regression analysis of data from 1969 to 2012. BMC Public Health. 2016 Mar 11;16:255. doi: 10.1186/s12889-016-2919-y. PubMed PMID:26968155.

4: Hogan MF, Grumet JG. Suicide Prevention: An Emerging Priority For Health Care.Health Aff (Millwood). 2016 Jun 1;35(6):1084-90. doi: 10.1377/hlthaff.2015.1672. PubMed PMID: 27269026.

Disclaimer:

I had no input into the Minnesota Suicide Prevention Plan and I know none of its authors.  I accessed it online and read it.

Open Psychiatric Units Mean Fewer Suicides and Elopements ?!!

There is a headline making the rounds in the media about whether or not locked psychiatric units are useful in preventing suicides and "absconding" behavior in inpatient psychiatric units.  Absconding is running away before the formal discharge and in the US it is referred to as elopement.  The media handling of this article is a bit less scholarly than you might expect from the average psychiatrist reading this article.  Even media circulating to psychiatrists sends out the headlines from a news service:  "Locked psychiatric wards may mean more suicide or escape attempts." Since I have spent the majority of my career on locked psychiatric units and consider myself an expert in this area - reading the article and looking at its deficiencies comes naturally to me.

The article looks at a coalition of 22 German psychiatric hospitals and their affiliated psychiatric services.  Sixteen of the hospitals had at least one locked psychiatric unit over the course of the study.  Four hospitals had no locked wards over the course of the study.  One of the hospitals started out with no locked wards but "had to introduce locked wards for legal reasons" in November 2000. organized under a central agency that looks at quality assurance and quality management.  Twenty one of the hospitals participated in data analysis by a central quality assurance/management agency the Dokumentationsverbund Psychiatrie (DVP).  The study period ran from January 1, 1998 to December 31, 2012.  This was  an entirely retrospective analysis based on anonymized data.  During the study period there were 271,128 admissions to locked wards and 78,446 admissions to open wards.

Primary outcome variable was completed suicide and secondary outcome variables were suicide attempts during treatment, elopement without return, and elopement with return.  Some of the characteristics of the populations were described and they appear to have diagnoses similar to what might be found on inpatient units in the US with major difference - some of the primary diagnoses listed would likely not be admitted - like somatoform disorder or personality disorder as a primary diagnosis, but the study says very little about admission criteria.  On American inpatients psychiatric units pure substance use disorders are actively discriminated against, by insurers and government agencies that govern hospitalizations and in the German sample. they constitute 18-25% of the primary diagnoses.  The authors do a statistical comparison between the locked ward and open ward groups across the outcome variables.               

There are two logical flaws with the study and the researchers comment on one.

The first is generalizability of the data.  The authors seem to recognize this in their use of OECD data and the rates of psychiatric bed utilization in Germany (2.8 per 1,000 population) versus the UK (0.5 per 1,000) and the US (0.3 per 1,000)  suggesting that there is greater acuity in the populations with fewer beds and that there is a greater proportion of acutely ill patients.  The other parameter that is critical in American inpatient psychiatry is the number of aggressive and homicidal patients.  At large metropolitan hospitals units comprised almost entirely of highly aggressive patients are not unusual.  Other patients are generally considered too vulnerable to be admitted to these units.

Aggressive behavior can create near riot conditions on units like this and an unlocked door would create numerous situations leading to violent confrontations with staff.  The striking part about this comparison to the German system was that this paper left out all mention of aggression, violence and homicide suggesting that these patients were not being admitted to these hospitals.  The only line containing these words in the entire paper was in one of the references.  That makes this study impossible to compare with any set of metropolitan psychiatric units in the US.  There is the associated question of what the Germans do with their aggressive patients?  Are they sent to forensic hospitals or specialized units?  It would be very unlikely to not encounter thousands of highly aggressive patients in any American sample this large even at a time when the largest psychiatric hospitals in the country are county jails.

The second is that the implicit notion about a randomized controlled trial.  For the reason I previously mentioned it is not likely to be ethical, amenable to human subjects approval or therefore doable.  The authors suggest that being under a mandate to treat all patients in a certain geographic area reduces selection bias.  That is difficult to accept if potential for aggression and overt aggressive behavior is not an admission criteria and if it not compared between the locked and unlocked units.      

That said, what can American psychiatric units learn from the German experience?  The first and most important is that unlocked units are possible.  I worked at a facility that typically had 4 psychiatric units and when we started one unit was open.  It was a transitional unit where people were sent after their acute disorder, agitation, aggressive behavior. and suicide risk was treated but they were not quite ready for discharge.  The management of psychiatric units by business managers eventually dictated that these partially stabilized people should just be discharged - frequently when there had been an almost imperceptible improvement.  This was all based on the fallacious "dangerousness" argument by managed care companies.  They decided about 20-25 years ago that the only reason anyone should be hospitalized on an inpatient psychiatric unit was if they were dangerous to themselves or others.  That also led to locked hospital wards, if not by implication by explicit managed care feedback as in: "If the patient does not need to be on a locked unit - they don't need to be in the hospital and therefore we are denying payment for this admission."  Have these managed care tactics dumbed down inpatient treatment and adversely affected the atmosphere of these units?  Of course it has.  It has created a palpable corrections-like atmosphere in many units.  The only reason people are there is to figure a way to get out.  This reinforces the thought that the people there really don't have any problems in the first place they are just being discriminated against.  So the first lesson from Germany is to restore the running of hospitals to psychiatrists and not business managers.

The second issue is infrastructure and length of stay (LOS).  Most EU countries have significantly more psychiatric beds available to their populations.  The most likely reason is that they are not rationed (nearly out of existence) by managed care companies or the government like they have been in the US.   Lengths of stay are also significantly greater.  The interesting dimensions for comparison would be the functional status of patient at discharge as well as the therapeutic milieu in comparing German to American units.  That would require a more sophisticated research approach but it might bring some science to inpatient psychiatric care.  It would also be interesting to know if the German hospitals have state of the art specialized programs for specific conditions and whether their environment is designed to emphasize the therapeutic rather than containment aspects.

There is also the opportunity to look at the administrative aspects of these units more specifically the impact of a business management approach to a more clinical or at least less of a short term profit approach.

We have all witnessed what healthcare businesses can do to inpatient care in the US - and it is never good. 

George Dawson, MD, DFAPA

References:

1: Huber CG, Schneeberger AR, Kowalinski E, Fröhlich D, von Felten S, Walter M, Zinkler M, Beine K, Heinz A, Borgwardt S, Lang UE. Suicide risk and absconding in psychiatric hospitals with and without open door policies: a 15 year, observational study. Lancet Psychiatry. 2016 Jul 28. pii: S2215-0366(16)30168-7. doi: 10.1016/S2215-0366(16)30168-7. [Epub ahead of print] PubMed PMID: 27477886.

Being Suicidal - The Conscious State

The assessment of potential for suicide is a large part of a psychiatrist's work.  Within the past decade these footnotes have popped up even in algorithms that are designed to guide decisions about psychopharmacology.  They have always been present in treatment guidelines for most major psychiatric disorders.  They are a major cause of anxiety for practitioners, because we all know that our predictive capacity is low, but more importantly we know that unlike Internists and Surgeons we have limited access to the resources necessary to address the problem.

Considering for a moment a typical outpatient crisis, for a person known in the practice with depression who is now clinically changed in an office assessment with suicidal thoughts, the options are very limited.  In the case of an assessment of extreme risk, inpatient treatment may be offered.  If the patient has any inpatient experience at all, he or she knows that inpatient units are generally miserable places where very little active care happens and where they are enclosed with a number of very ill patients.  They may also know that there are an arbitrary number of hoops that must be jumped through in order to be discharged and that as a result they may be in that environment much longer than they need to be.  They may also have had a typical experience of the inpatient psychiatrist not talking with their outpatient psychiatrist and making a number of abrupt medication changes that are neither necessary or indicated based on their brief familiarity with the case.  For those reasons and also because most people are averse to sitting in hospitals - people will balk at the suggestion of inpatient care.

The suggestion of inpatient care also assumes there is the availability of that option in the community.  Most hospitals in any given state do not offer inpatient psychiatric care.  That level of care has been discriminated against at a political and financial level for 30 years and as a result hospital services and inpatient psychiatric beds have contracted in an expected manner.  Patients are often transferred hundreds of miles within states to reach these beds.  A related issue is the availability of electroconvulsive therapy (ECT) for severe depressions.  In the case of high risk depression it may be the only effective option.  Many states have no availability of this option for patients who need it.

The suggestion of emergency department (ED) care is an even bigger dead end.  The vast majority of ED care is provided by mental health professionals who are not psychiatrists and who are making triage decisions that ED physicians can sign off on.  The wait is hours and if a high risk determination is made it might be days in the ED before any disposition can be made.  Patients are often discharged on the basis of whether their suicidal ideation is chronic or not and whether they are saying that they have a suicidal thought and an intent to harm themselves right at the time of the assessment.

All of the above factors generally place the burden of care back on the original treating psychiatrist, even when the risk is higher that he or she would want.  Most psychiatrists recognize that if they are treating very ill patients, there needs to be an element of acceptable risk in order to provide treatment and the hope of recovery.  Psychiatrists realize that resources are severely rationed, that their patient needs acute treatment, that the patient will only accept certain treatment, and that there is a societal expectation of medical paternalism if the patient in not able to remain safe.   The psychiatrist and the patient are frequently operating in this zone of acceptable risk that is perceived very differently by others.  Family members are the clearest case in point.  Like society in general, many family members have their biases when it comes to psychiatry.  Many have been instrumental in discouraging their family member from getting treatment.  In some cases they have interfered with treatment and suggested that the family member discontinue treatment or throw away any medications that they have been taking.  At the same time, family members generally favor a zero risk treatment environment.  They would prefer that the patient's suicidal thinking resolve completely so that there is no risk that they will attempt suicide.  They see suicidal thoughts as controllable and the product of a series of correctable decisions.  They don't understand why the thoughts just can't be turned off by the patient, their psychiatrist, or in some cases - the medication the patient is taking.  In extreme cases, they may threaten litigation if the patient suicides or makes a suicide attempt implying a volitional and controllable basis for suicidal thinking.

An understanding of human consciousness provides a way to analyze this situation and the misperceptions about suicidal thinking and behavior.  The predominant model of risk assessment for both suicidal ideation and aggressive potential is risk factor analysis.  It generally proceeds from an elaboration of the specific thoughts to past history of attempts, availability of lethal means, diagnostic risk factors, past history and analysis of attempts, and specific demographic risk factors associated with suicide attempts.  Many texts like the Harvard Medical School Guide To Suicide Assessment and Intervention have detailed approaches to the problem and further conceptualizations like proximate and distal risk factors.  In an earlier post, I discovered a checklist of risk factors that looked at the issue of Increased Reasons or Decreased Barriers to suicide called the Convergent Functional Information for Suicide Scale (CFI-S).   Many institutions these days prefer the Columbia Suicide Severity Rating Scale (C-SSRS).  All of these methods are essentially based on risk factor analysis.  Some are more elaborate than others.  There all estimate risk to one degree or another and in some cases factors that mitigate risk.  I won't debate the merits of these methods here.  All that I want to say about them is that after the risk has been estimated, the psychiatrist may still be working with a high risk patient who is unpredictable in both an inpatient and an outpatient setting.  Interventions can be initiated to reduce the risk, but there is no assurance that they will be effective fast enough to prevent a suicide attempt.  In many clinics where a standardized approach like this is used with an electronic health record and a cutoff score is used to determine risk, a psychiatrist may find the patient visits being flagged for months or longer based on these numbers.

Is there another model that might supplement or improve upon the risk factor analysis models?  For about 15 years now, I have been looking at a model that considers the basic question of what happens when a human conscious state shifts from one that would never contemplate suicide to one that does or in the extreme state proceeds rapidly to suicide.  The usual psychiatric model considers the development of an illness state like depression, bipolar disorder, borderline personality disorder, or alcoholism as a precursor state.  The cognitive changes, like depressogenic thinking seen in the precursor states are seen as the basis for suicidal thinking.  The intervention is generally directed at reversing the precursor state, acutely structuring the environment as necessary for safety, and direct verbal interventions to address the suicidal thinking.

It is possible to explore with people the transition of their conscious state from a person without suicidal thinking to a person who develops suicidal thinking and consider a broad array of associated factors.  Just being able to recognize that this transition has occurred is an important part of any evaluation and intervention.  Some people are so severely depressed that it seems like the suicidal thinking has been there forever.  They can barely recognize a time when they felt better or were not suicidal.  In many cases they are preoccupied with existential factors such as meaningfulness of their life, personal freedom, and of course life and death - factors that they were only peripherally focused on during their daily life.  In some cases they are important psychodynamic factors such as the death of a family member or friend from suicide.  I speculate that many psychiatrists have heard of or been involved in situations like this.  These events are also described in some of the psychoanalytic literature but not necessarily the risk factor analysis literature.  John Bowlby described some examples in his book Loss:

"From many examples from Cain and Fast we select two: one eighteen year old girl who drowned herself alone at night in much the same fashion as had her mother many years earlier;  the other a thirty-two-year old man who drove his car over the same cliff that his father had driven over twenty-one years earlier.  Some of these individuals, it seems, had lived for many years with a deep belief, amounting to a conviction, that they will one day die by suicide.  Some quietly resign themselves to their fate.  Others seek help." (p. 389)

Of course the complexity of this situation is much greater than Bowlby can capture in his brief explanation.  Just at the psychodynamic level there is the issue of identification with the parent and their suicidal actions.  Do they believe that they have a deeper understanding of the parent's action and consider them to be logical?  Have they incorporated this into their worldview and consider it to be their fate?  At the neurobiological end of the spectrum, is it a case of straight genetic vulnerability to suicide or were there epigenetic factors related to a severe disruption of the home environment that the suicide of a parent can cause?  Do they remember an event or series of events during childhood when the affected parent seemed to transmit a tendency to anxiety or depression directly to them?  All of these are relevant considerations when examining what is going one at the conscious level in an individual who has become suicidal.

Elementary risk factor analysis also benefits from the broader perspective of considering other conscious factors.  It allows for an exploration of additional degrees of freedom.  For example, the issue of firearms possession and the elaboration of risk often depends on possession and risky behavior with that gun.  But what constitutes risky behavior and what needs to be asked?  Have you had the gun in your hand when you were thinking about suicide?  Was the gun loaded?  Did you actually point the loaded gun at yourself? What were you thinking about at that time?  The questions and responses cannot be anticipated in a linear risk factor analysis or algorithm.

A nonlinear consciousness approach can also incorporate an informed consent approach to provide active feedback to the patient on the current risk and the limitations of treatment.   This often opens a window into the dynamics of how the patient conceptualizes risk and their ability to work with the psychiatrist in minimizing it.  A more linear assessment often takes on the structure of the psychiatrist trying to guess whether or not the patient is going to kill themselves and leaves the patient as a relatively passive participant.  A consciousness based approach recognizes that the patient has entered at least partially into a conscious state that is foreign to them, less predictable, and represents some degree of risk to them.  They need to hear very clearly that they and the psychiatrist need to work together to restore their baseline conscious state and reduce risk in the meantime.  The process encourages them to not leave the interview leaving something that is potentially important - unsaid.  


George Dawson, MD, DFAPA      


References:

1:  John Bowlby.  Attachment and Loss - Volume III: Loss - Sadness and Depression.  Basic Books. New York.  Copyright by the Tavistock Institute of Human Relations.  1980, p 389.

2:  Douglas G. Jacobs (ed).  The Harvard Medical School Guide to Suicide Assessment and Intervention.  Jossey-Bass Publishers; San Francisco.  Copyright by the President and Fellows of Harvard College. 1999.

Patentable Biomarkers of Suicide

From: Understanding and predicting suicidality using a combined genomic and clinical risk assessment approach (reference 1 with permission).

One of the most interesting aspects of biological psychiatry is the attempt to characterize complex biological systems.  It may not have been apparent but complex biological systems factored in a recent post about bronchitis.  Lungs are certainly complex with two different blood supplies and complicated immunology, but the lungs are not thinking organs.  They don't come up with any secondary concepts that need to be analyzed as possible derivatives of the biological substrate.  And even then, basic syndromes that we all learned about in medical school and in clinical rotations, defy more useful classifications.  I have previously posted on endophenotypes and their usefulness in the treatment of asthma and only recently noted that they have proliferated to include an obese endophenotype and how that affects response to therapy.  Diagnostic and treatment approaches to asthma and bronchitis are necessarily crude, largely because the biological complexity in these processes is not fully appreciated and addressed.

The brain is certainly the most complex organ in the body.  Cellular arrays in the brain produce a stream of consciousness, robust unconscious processing, unique conscious states, and all forms of emotional, social and intellectual constructs that can be observed, monitored, and changed.  That brings me to a paper from Molecular Psychiatry on possible biomarkers for suicide.  Not just any paper - at this point it is the most downloaded paper from the top-ranked psychiatry journal (1/140) in the world.  Molecular Psychiatry has an impact factor of 14.496 and that is the highest impact factor of all psychiatry journals.  In part that is probably driven by how absurdly expensive that similar journals like Biological Psychiatry are or other barriers to purchase like needing to be a member of the sponsoring society.  This is a public access journal that uses Creative Commons Licenses for their content.  The authors in this case have provided a 20 pages article and 124 pages in Supplemental Information.

The idea of a biomarker for suicide is very attractive to psychiatrists, because assessing suicide risk is a big part of what we do.  Current clinical guidelines suggest that we need to make that assessment at every patient visit.  The actual prediction of suicide is difficult due to the fact that mental states change over time and people may not be able to communicate their true level of risk.  I have had people tell me in retrospect that they lied about their degree of suicidal thinking and level of control when I asked them about it.  I have had acute care colleagues tell me that they were weary of having to guess about whether a person was going to try to kill themselves or not - many times a day.  The assessment is further complicated by a lack of acceptable acute care options that may further hinder complete self disclosure.  A biomarker would potentially be beneficial.  I qualify that by the fact that the dexamethasone suppression test was once considered a biomarker of suicide (1), but these days it is rarely done and certainly not as part of a suicide assessment.  A study by Coryell, et al (9) notes that the DST was not able to differentiate patients who died from suicide or cardiovascular disease when long term mortality was determined by the National Death Index.  Those authors suggest it may be useful as a predictor of suicide only in patients with depression.

In this article the authors take a look at possible biomarkers in blood that could predict both suicide and some associated markers like risk of hospitalization.  There is a lot going on in this paper.  All the research participants were men.  They studied four different patient cohorts including 217 patients followed longitudinally.  This group was called the Discovery Cohort because markers were discovered based on 37 patients who had a switch from a no suicide state to a high suicide state defined as a score of 2 - 4 on the HAMD question about suicide.  26 deceased patients who committed suicide were used to validate the initial markers.  Two psychiatric cohorts of 108 and 157 to look at prediction of suicidal ideation and hospitalization with the chosen tests.  The flow of these experiments in depicted in the graphic at the top of this post from the original paper.  In the diagram, the designations AP (absent-present) and DE (differential expression) are techniques to capturing genes that are turning of and turning on and off and gradual  changes in gene expression.  The respective genes in this analysis are color-coded based on those properties.  The Convergent Functional Genomic (CFG) Approach is depicted in the box.  Candidate genes are ranked in the triangles according to CFG score.  The CFG score was the sum of various weighted factors including evidence of human brain expression, evidence of human peripheral presence, human genetic evidence and linkage with weighted scores in the CFG box.  Using their discovery and validation sequence the authors were able to pare down the total number of genes down from 412 to 208 to 143 and ultimately to 76 genes.  The supplementary information provides the validation of biomarkers and a table that looks at each gene and prior human genetic evidence, prior evidence of brain expression and prior human evidence of peripheral expression.

The authors discussion of the biological relevance of their findings was interesting.  They did pathway analysis looking at Ingenuity, KEGG, and GeneGO databases.  Of these only the Kyoto Encyclopedia of Genes and Genomes (KEGG) is publicly available without a subscription fee.  It is very useful to know about KEGG because of the relevance of pathway analysis in the psychiatric literature.  As an example, I have been teaching about the mTOR pathway discussed in this article in my neurobiology of addiction lectures for the past 4 years.    

This article is very interesting and can be read at  several levels.  It is premature to consider it definitive at this point and based on this paper and the work of the associated lab these authors are working on additional validation strategies.  If they are  correct,  suicidality may be captured in time as a polygenic event based on a combination of genes that are turned off and on and others that gradually change.  I titled this post as "patentable genes" because the only conflict of interest cited is the lead author is listed as an inventor on a patent application being filed by Indiana University.  For trainees and early career psychiatrists a familiarity with this technology and its potential uses and limitations would be one of the reading goals and including Molecular Psychiatry and its sister journal from the same group Translational Psychiatry (8) is probably a good idea.  Both are potentially good sources of neuroscientific information in psychiatry and if popularity is any indication - fill a niche in the field.  Some of the tools that they developed along the way are useful to think about from a clinical perspective (4, 5).  The thought that the CFI-S Scale was particularly interesting because it is a 22 point binary scale that looks at factors (excluding suicidal ideation) that they determined to be important.  The factors are also classified as to whether they represent increased reasons (IR) or decreased barriers (DB) to suicide.  The emphasis on suicide as a discrete syndrome independent of diagnosis is a research strategy that has been called for recently based on the need to come up with better ways to diagnose and treat the problem.  In a clinical setting I think that clinicians are still frequently surprised by suicide attempts and suicides being able to determine if a patient is in a high risk state based on a blood test independent of their clinical presentation and statements would be useful both in terms of the test but also the associated dialogue.

What I really like about this paper is that it is an attempt to deal with a common psychiatric problem at the appropriate level of complexity.  Clinical trials do exactly the opposite.  As an example, clinical trials in psychiatry will look at heterogeneous groups of patients pulled together under a vague diagnostic category.  There may be rating scales or global ratings just because the rating scales don't seem to have much discriminatory power.  In the end, the entire study is generally collapsed for a very simple statistical analysis.  Getting to those final variables and what has been ignored in the process is always the critical question.  I think it is trendy these days to commiserate about the fact that there are inconclusive, weak and non-reproducible results from the standard clinical trials technology.  I don't know why anyone would expect a different result.  If anything this paper illustrates that a lot of biological information can be considered and analyzed.  The popularity of this paper leaves me hopeful that this is a positive trend for the future.            


George Dawson, MD, DFAPA


References:

1:  Niculescu AB, Levey DF, Phalen PL, Le-Niculescu H, Dainton HD, Jain N,Belanger E, James A, George S, Weber H, Graham DL, Schweitzer R, Ladd TB, Learman R, Niculescu EM, Vanipenta NP, Khan FN, Mullen J, Shankar G, Cook S, Humbert C, Ballew A, Yard M, Gelbart T, Shekhar A, Schork NJ, Kurian SM, Sandusky GE, Salomon DR. Understanding and predicting suicidality using a combined genomic and clinical risk assessment approach. Mol Psychiatry. 2015 Aug 18. doi: 10.1038/mp.2015.112. [Epub ahead of print] PubMed PMID: 26283638.

2:   Lee BH, Kim YK. Potential peripheral biological predictors of suicidal behavior in major depressive disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2011 Jun 1;35(4):842-7. doi: 10.1016/j.pnpbp.2010.08.001. Epub 2010 Aug 11. Review. PubMed PMID: 20708058.

3:   Collection of references for biomarkers in suicide.

4:  Simplified Affective State Scale (SASS).

5:  Convergent Functional Information for Suicide (CFI-S) Scale.

6:  Laboratory of Neurophenomics Web Site.

7.  Niculescu AB Medline Collection on additional convergent functional genomics references.

8.  Translational Psychiatry Web Site.

9.  Coryell W, Young E, Carroll B.  Hyperactivity of thehypothalamic-pituitary-adrenal axis and mortality in major depressive disorder.  Psychiatry Res. 2006 May 30;142(1):99-104. Epub 2006 Apr 21. PubMed PMID: 16631257.

Attribution:

The figure at the top of the post is from the original article listed completely in reference 1 under a Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License.  To view the condition of that license view it here.

Supplementary:

1.  There is a Mayo Clinic Conference coming up this fall for anyone interested in translational approaches to psychiatric disorders and addictions.  Further information is available at this web site.

2.  There is also the 3rd Annual Update and Advances in Psychiatry conference at the US Madison and one of presentations is by Daniel Weinberger, MD on the neuroscience of schizophrenia and psychotic disorders.   Information on that conference and the conference brochure is available at this web site.

The Chai Man

Back in the 1970s I was in the US Peace Corps in Kenya East Africa.  I worked in an all boys school as a chemistry teacher.  The school was about 100 miles north of Nairobi on a high plateau next to Mt. Kenya.  On the weekends my fellow volunteers and I would drive over to the closest town for a Coke and an inexpensive snack at the White Rhino Hotel.  In those days a Coke or a bottle of beer would cost about a Kenyan Shilling (KES) and a meat pie or a samosa would cost about a Shilling and a half.  One Shilling was about 14 cents American.  Outside the hotel was an apparently homeless man.  He would beg for money often by creating disturbances.  He would obstruct people in the street going to and from the hotel.  He would shout out the word "Chai,  Chai..." repeatedly while spitting down the front of his shirt.  "Chai" is the Kiswahili word for tea.  He would appear agitated and tearful at times.  He was not tolerated very well by hotel security or the local people - people who could speak fluent Kiswahili and the local Kikuyu language.  Some of them would become physically aggressive toward him and cause him to run down the street.  At other times he would show up with a can of dirty water and try to clean auto windshields by wetting down a newspaper and wiping the water all over.  These attempts were always unsolicited and the drivers would become enraged because their windshields were always less clean than when he started.  We eventually referred to him as the Chai Man because nobody ever knew his name.  The Chai man clearly struggled, alienated practically every person I ever watched him interact with, and he got minimal assistance from anyone.  At the time he reminded me of homeless men I would see in my local public library.  It was the only they place they could go in a small town to get a break from the weather.  They would occasionally ask for money, but for the most part avoided people.  When  you are down and out and mentally ill, most people seem to know better than to ask.

By the time my fellow teachers and I made it to our placement north of Nairobi we had contact with hundreds if not thousands of people living on the street as beggars.  Many had physical deformities to the point that they were unable to walk.  Coming into town from the airport was enough contact to convince the most altruistic Peace Corps volunteer (PCV) that they personally did not have nearly enough resources to address the problem.  PCVs had to learn to not look at the people begging on the street and walk quickly by or risk people coming out and grabbing their leg or arm until they were given money.  Like the US, only certain streets and areas allowed for the aggregation of these homeless beggars.  PCVs were not rich by any means but when we got to our eventual destinations, they were usually places where there were no homeless people in sight.  We were rather scruffy ourselves but we could sit in classy places like the New Stanley Hotel and sip on a Coke.

I thought of the Chai Man last night as I listed to a program on "The World" on MPR about a mental health initiative in Kenya (reference 1).  The focus of the program was a young woman Sitawa Wafula started mental health crisis intervention service on her own.  It is a formidable problem.  The program describes how children and adults are "locked up" by their families and may not see the light of day.  Neighbors often do not know that a mentally ill brother or sister exists.  This is reminiscent of Shorter's description of the problem of psychosis in Europe and how it was handled in the early 20th century.   It also happened in my own family in the early 1950s.  In Kenya, there are currently 79 psychiatrists or one for very 500,000 people.  Ms. Wafula gets a number of calls to her crisis intervention service and says that if the problem involves suicidal thinking many people with that problem have had two previous suicide attempts.  The World Health Organization puts Kenya in the top quartile of suicide rates in all countries worldwide.    

I was picked up by a Kenyan physician once when I was hitchhiking back to Nairobi one  day.  I asked him what was available in terms of psychiatric services at the time.  He said there was only one hospital and that the basic medication being prescribed by physicians was chlorpromazine.  At that time, the chlorpromazine generation of antipsychotics were the only ones available and antidepressants were more difficult to prescribe.  Medical care in general was difficult to access.  I would typically get scabies at least one a month.  When I was initially infected I made the mistake of going to a local clinic and standing in line in the hot sun.  I was about number 300 in the line and it moved about 4 or 5 spaces every hour.  I realized that I could hitchhike 100 miles to Nairobi and back and pick up the appropriate treatment from the Peace Corps physician in less time than it took to go to the local clinic.  Eventually I just picked up a large bottle scabicide and applied it whenever I got infected.   At the time Kenya also had one of the fastest growing populations making it more difficult to provide medical and psychiatric care.

About 8 years after I left Africa, I was sitting in a seminar full of fellow psychiatry residents at the University of Wisconsin.  The topic of the day was whether or not the prognosis of schizophrenia was better in what was then called the "the third world" based on some outcome studies available at the time.  Our job was to critique the literature and it was apparent that there were technical differences in studies and in many areas the follow up and methodology was different.  At one point I suggested that exposure to antipsychotic medications may lead to negative outcomes and that raised an eyebrow or two.  I also pointed out that that at least half of the people I was treating had significant alcohol and drug problems and were not interested in quitting.  I doubted that many of the people in these studies had widespread access to street drugs that were known to precipitate psychotic states.  I remembered the Chai Man very well, but knew better than to introduce my anecdotal experience from Kenya.  That axiom about better prognosis in the developing world has since been re-examined (reference 2) and there are clearly more problems with that theory than originally thought.  Like many areas in psychosocial research it may depend more on your political biases before you read the research.  The Scandinavian research on brief psychosis and brief reactive psychosis from about the same time frame certainly suggested similar rates of spontaneous recovery.

These experiences make me smile at couple of levels.  Any time someone "confronts" me with the evidence of prognosis in schizophrenia and the World Health Organization (WHO) studies, I can point out I had a better and more thorough discussion about it with fellow psychiatrists in 1986.  I have also lived in a developing country and saw how people with presumptive mental illnesses were treated.  I have applied that experience and knowledge to clinical practice in this country.

There is the curious parallel of access to psychiatrists in both countries.  How do the citizens who need them the most get access to them?  The public radio story suggests that only people with resources (I take that to mean money) can get access to the limited number of psychiatrists in Kenya.  This country is headed in the same direction largely because rational psychiatrists do not want to be ordered around by insurance companies.  In the case of access for the severely disabled, individual states have different plans but the overall plan has been to ration access and incarcerate rather than hospitalize people with mental illnesses.  In the US, there is generally an order of magnitude greater number of psychiatrists, but that does not translate to more access.  I have talked to too many people who stop seeing a psychiatrist when their insurance stops.  The insurance industry, state governments, and the federal government all have an interest in restricting access to psychiatrists.   If people only see psychiatrists if they have poor insurance coverage and psychiatrists are fleeing insurance - this is a chronic problem that will only get worse.  

In the meantime, I hope that Ms. Wafula continues to be successful in her crisis intervention program and raising awareness that severe mental illness is a public health problem that needs to be addressed.  Families should have more resources and more help.  The WHO program to raise awareness about suicide also seems like a good idea.


George Dawson, MD, DFAPA


References:

1.  Emily Johnson.  Fighting the 'funk:' How one Kenyan battles her mental health problems by helping others.  PRI The World.  March 3, 2015.

2. Cohen A, Patel V, Thara R, Gureje O. Questioning an axiom: better prognosis for schizophrenia in the developing world? Schizophr Bull. 2008 Mar;34(2):229-44. Epub 2007 Sep 28. Review. PubMed PMID: 17905787



Supplementary 1: The map graphic is from the CIA Factbook in the public domain.

Supplementary 2: WHO Infographic on Suicide.

Supplementary 3:  I mention the New Stanley Hotel in this post, but sometime after I was there it was blown up by terrorists.  The replacement versions (at least according to Google) continue to be threatened by terrorists, who apparently want to target the tourist business in Kenya.

Advice To Residents - continued

A couple of things to add to the previous list:

17.  Information - One of the most formative documents that I ever read was Shannon and Weaver's paper on communication theory.  My only reason for reading this paper in the first place was cultural.  I was an undergrad during tumultuous times and learned about this paper in the Whole Earth Catalogue.  Since it was a technical and engineering document I was very surprised to find it in my liberal arts campus library.  After becoming a psychiatrist I have been very aware of the information content and exchange between physicians and patients.  Despite the lack of any quantitative analysis, there are no big surprises.  The more information exchanges the more accurate the diagnosis and the better the treatment plan.  That has implications for how you approach clinical work.  Physicians interested in information tend to maximize the data points they put into their assessments.  They also make a point of getting plenty of collateral data.  They pay more attention to high signal to noise information and learn to set limits on sources where there the signal is low.  It takes discipline to focus on information optimized exchanges in this day when physicians are often their own transcriptionists.  It is also difficult when electronic health record systems degenerate into binary checklists that do not allow for the documentation of unique data.  A focus on information leads to consistently high quality care.


18.  Suicide - Any finalized version of this list will give suicide a much higher priority.  It is always with us.  I know for a fact that the unpredictable aspect of suicide prevents many excellent physicians from going in to psychiatry.  Any professional guideline states that suicidal ideation and potential needs to be assessed on a longitudinal basis at every meeting with the patient.  Residents are immersed in the treatment of a combination of people who are at very high risk for suicide and/or chronically suicidal.  They are taught the very blunt instrument of risk factor analysis to make those decisions.  They are expected to perform contentious interventions to hold people against their will based on the assessment of suicidal behavior.  Residents in every class will lose patients to suicide and will experience a great deal of emotional turmoil related to that loss.  It is the most difficult aspect of the field to negotiate.

What is the best approach to the problem of providing the best possible care to people with suicidal ideation and behavior and minimizing the emotional toll on yourself?  There are three basic considerations.  The first is technical aspects of assessment and treatment.  There has been a recent revival of interest in suicide as a problem independent of diagnosis so I would follow that area of research.  As far as I can tell, The Harvard Medical School Guide To Suicide Assessment and Treatment is still a unique source of information.  On the assessment side not missing psychotic depression is critical and it can be a subtle finding.  The second is the countertransference aspects of care for the suicidal person.  People who are chronically or recurrently suicidal elicit strong emotions in people.  Some of these emotions are readily observable in their friends and relatives.  Recognize them in yourself and figure out what to do about them.  Finally the single best piece of advice is to always make sure that you have done everything possible to prevent the suicide of a patient.  Suicide is a rare event but if it occurs making sure that you did not miss anything is the best way to moderate your emotional response.  The last few sentences seem a lot more straightforward than they really are.  There are always a number of obstacles to the best possible care that you will not have control over.  It is still important to discuss the optimal plan with the patient.  An additional safeguard as a resident is to ask your supervisor: "Is there anything else that you would do in this case to address the patient's suicide potential?"  As a supervisor, I think that is a fair question that I should be able to answer.

These two points came to me since the original post.  The point about suicide was an obvious omission suggested by a colleague.  It highlights the fact that even a senior psychiatrist like myself can omit important points that can be corrected by collegial consultation.

Please feel free to send me any additional points or sources that you have found useful.  The Harvard Medical School Guide.. is dated at this point and I don't think that there has been an updated edition  or any source that improves upon this information.  I have my own approach to this problem that I think is useful to consider, but I am reluctant to post it here without any peer review.

My pep talk to residents at times involves reminding them how tough this field is.  It is intellectually and emotionally rigorous and to do a good job you have to stay focused and at times be fairly hard on yourself.  You also have to check out what you are doing with other psychiatrists - supervisors as a resident and colleagues when you are in practice.    



George Dawson, MD, DFAPA   


Reference:

1.  Aleman A, Denys D. Mental health: A road map for suicide research and prevention. Nature. 2014 May 22;509(7501):421-3. PubMed PMID: 24860882.

Supplementary:

1.  The first 16 points of this thread are contained in the previous post.

JAMA Psychiatry Suicide Article, Statistics and AI

Suicide Rates - Selected OECD Countries

Suicide is a very important problem for psychiatrists.  Even though it is a rare event, it seems like most of our time is focused on preventing suicide.  There are many days where many high risk patients and patients with chronic suicidal ideation are seen in clinics and hospitals.  Most of them are treated in outpatient settings and very few are treated on an involuntary basis in hospital settings.  Since suicide is diametrically opposed to self preservation it is assumed that any rational person would want to get help with those thoughts and impulses.  Like most things in psychiatric practice it is almost never than simple.  Psychiatrists encounter a wide range of of reasons for suicidal thinking.  At times, the suicidal thinking was not obvious until it was declared after a suicide attempt.  Many people decide to see psychiatrists after a first suicide attempt.  Even at that point it is common to find a person who is disappointed that they did not succeed.  It is more common to find a person greatly relieved that they survived but even then that does not assure the cooperation necessary to prevent another attempt.

The standard of practice for assessing suicidal thinking or ideation and potential risk is risk factor analysis.  This has been the standard of practice for as long as I have practiced over the past 30 years.  To do this analysis, it requires making a diagnosis or a series of diagnoses and looking at associated factors and how the patient describes his/her mental state at the time.  Major psychiatric diagnoses like major depression, schizophrenia, bipolar disorder, panic disorder, borderline personality disorder and chronic substance use disorders all have significant lifetime prevalences of suicide varying from 3 to 15%.  Psychological autopsies of series of suicides find that nearly all of the patients who have suicided in these studies had a significant psychiatric disorder.  There are also studies done from a social science perspective that emphasize the social risk factors for suicide including sex, martial and relationship status, economic factors and loss.

Suicide is a widely misunderstood problem sometimes even for the patients who are experiencing the thoughts.  It is common for example to encounter people with suicidal thinking who say that their only deterrent to suicide is that they don't "have the guts" to do it.  An associated worry might be that it is "too painful."  They feel a need to explain why they cannot carry out an irrational act.  I take this to mean that at some point in time, the suicidal person's conscious state has changed.  They are no longer a rational person and that is why they must explain away the fact that they cannot carry out an irrational act.  Another common observation that speaks to the conscious state is that many people will say "I never understood how a person could be suicidal until I finally felt that way."  That suggests that the altered conscious state is associated with a mood state of depression or many times a mixture of depression, anger, and anxiety resulting in an agitated state that led to the understanding about suicidal thoughts.  A final observation is one of the most stressful parts of psychiatric practice and that is:  "Can I believe this person when they tell me they are not going to kill themselves?"  Much of acute care psychiatry hinges on that ultimate question.  The risk factor analysis is essentially nullified if the patient is in an emergency department and their diagnosis and past suicide attempts are known.  The only thing left to go on are the standard questions about current state of mind, deterrents, safety plans and whether the person seems reliable and says they will not kill themselves.   It is widely known that people kill themselves after leaving emergency departments and hospitals.  People have killed themselves in hospitals while under direct observation.

Many of these assessments become adversarial.  By the time a psychiatrist sees a patient in a hospital, a lot has already happened. In all of the hospitals where I have practiced, crisis teams, paramedics, and the police have assessed the person in the community and brought them in to the hospital.  Very few people were under psychiatric care at the time of that intervention.  Friends and family members of the patient were the people who called the first responders.  The patient is usually there out of some concern for their welfare that they may not be aware of.  The psychiatrist comes around sometime in the next 24 hours and the interaction unfolds.  Very few people seem interested in the fact that they might kill themselves.  Getting out of the hospital may be the priority.  Their approach might be one of non-disclosure or denial: "I really did not say I was suicidal." or "I did not mean it",  or "I was drunk or high at the time".  Even those responses can vary from very unlikely (as in a patient with a serious self inflicted gunshot wound) to unlikely (a patient with delusional depression stopped in the midst or a suicide attempt) to possible (the intoxication history with no suicidal ideation while sober).  The interview dynamic is also quite variable.  A person may be sullen, irritated, and not wanting to discuss much information.  They may express concerns about self incrimination: "I know what I can and cannot say to psychiatrists.  I know if I say the wrong thing you will lock me up and throw away the key."  They may blame their problems on the psychiatrist: "Look - I know you don't care about me.  The only thing you care about is covering your ass.  You are going to do whatever you want to do."  They may be more hostile and sarcastic: "Look if I was really going to kill myself I wouldn't be sitting here talking to you.  I'd be dead.  I wouldn't be talking about it."

All of these statements ignore the fact that the person is sitting in front of the psychiatrist as the result of the actions of several other people including persons affiliated with them and having their best interests at heart.  That situation is so intense and uncomfortable that it prevents physicians from going into psychiatry.  I  have had many physicians tell me they could not go into psychiatry because:  "Guessing about whether or not a person will kill themselves is too stressful."  There are many ways to reduce the guesswork involved but the point I am trying to make here is that all of these behaviors are consistent with the patient having undergone a change in their conscious state.  They are no longer acting like a person interested in self preservation, but they are now a person who is contemplating self destruction and taking active measures to hide that thought pattern.  That is the main reason why psychiatrists can't predict suicide over long periods of time with any degree of certainty.  When a person's conscious state changes that completely, their actions are less predictable even to the point that they may be potentially self destructive and want to cover it up.

That is also why risk factor analysis is so imperfect.  In the case of the diagnosis, a lot of clinicians are under the impression that if a person satisfies some written criteria for a diagnosis that provides a lot of critical information about the potential for suicide.  Many clinicians seem to miss the point that a patient can have the exact same written criteria for major depression with psychotic features and the same chronic markers on a suicide risk assessment and suddenly be much more likely to attempt suicide.  The only thing that has changed has been the patient's conscious state and their awareness that suicide is an unwanted state.  The evidence that this happens is clinical and ample.  Patients will report back to their psychiatrists that they were in this conscious state and the psychiatrist did or did not miss it.  Either way, there is no clinician in this situation who could make the correct call.  Without any clear markers, there is no way to figure out if this change in conscious state has occurred.  The patient usually recognizes it only in retrospect.

This clinical information on the assessment of suicide is what makes this JAMA Psychiatry article interesting.  In this article the authors attempt to determine predictors of suicide by soldiers in the year following psychiatric hospitalization within the Veteran's Administration hospital system over a 6 year period.  That was a total of 40,820 hospitalizations or 0.9% of the total Army personnel in any 12 month period.  During that time there were a total of 68 deaths by suicide.  That is number is 12% of all US Army suicides.  The authors consider a long list of potential risk factors that are largely demographic in nature to determine concentration of risk of suicide.  That list includes a law enforcement data base that clinicians do not have access to.  Their overall goal was to determine of it was practical identify high risk patients for post hospitalization intervention and whether that might be a cost effective way to prevent suicide.  They were able to identify the highest risk group - the 5% of hospitalizations in which 52.9% of the suicides occurred.  Like many similar studies the authors also comment on  how their "actuarial" methods usually trump clinicians making the same predictions.  I found very limited commentary on that fact that it is generally possible to illustrate what you want with enough variables or as we used to say "a large enough spreadsheet".  In this case they looked at a large number of variables to come up with 421 predictors for further analysis.  I have reviewed hospital records consisting of the printout of the electronic health record where there were scarcely 421 words and it was usually impossible to determine an admission or discharge date.  Any information on even a short term assessment of suicide risk is scant and it frequently says basically that the patient told us he or she was not going to make a suicide attempt.  In some cases a rating scale approach like the Columbia is used.  Clinicians using these scales are often surprised about how few variables change after the initial rating and how the numerical risk does not necessarily reflect an inpatient versus and outpatient population.

As I read through the article, I was also impressed with the amount of alien statistics and fairly esoteric statistical terms.  If JAMA Psychiatry wants to include these methods, I think an example of the calculations and a bibliography of additional reading would be a minimal requirement.  The addition of statistical reviewers' comments or an independent statistical discussion of the pros and cons of these methods would only enhance the quality of the discussion.  One of my concerns is that as the statistical methods get more abstract and vague notions about big data are more accepted, clinical complexity and wisdom are completely diluted down and out.  I saw a headline the other day that Internet sellers know more about your "personality" than your spouse.  It should be fairly obvious from all of the healthcare research done that is based on HEDIS (The Healthcare Effectiveness Data and Information Set) information, that demographic variables and product choices are not the same thing as clinical assessment and treatment.

If the headlines about artificial intelligence replacing doctors ever comes true, it will only happen if the machine can implement the required knowledge.  The performance of computers sifting through text based findings and diagnostic criteria has been know for 20 years (reference 3).   Those data points were generally far superior to demographics.  I owned 2 of those programs and they don't bother to sell them anymore.  In terms of the assessment and treatment of suicide a knowledge base included in the Harvard  Medical School Guide To Suicide Assessment and Intervention might be a step in the right direction.  A lot of that knowledge depends on the skill of a particular clinician and that includes the personality factors of clinicians who continue to do this impossible job day after day.      

Trying to predict suicide and prevent it can't currently be done with an algorithm.  If I see an algorithm I will consider why the high risk people aren't being seen in follow up from the hospital rather than who should get an intervention.   And I would not mind errors on the false positive side.


George Dawson, MD, DFAPA

1:  Kessler RC, Warner CH, Ivany C, Petukhova MV, Rose S, Bromet EJ, Brown M 3rd, Cai T, Colpe LJ, Cox KL, Fullerton CS, Gilman SE, Gruber MJ, Heeringa SG, Lewandowski-Romps L, Li J, Millikan-Bell AM, Naifeh JA, Nock MK, Rosellini AJ, Sampson NA, Schoenbaum M, Stein MB, Wessely S, Zaslavsky AM, Ursano RJ; Army STARRS Collaborators. Predicting Suicides After Psychiatric Hospitalization in US Army Soldiers: The Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry. 2015 Jan 1;72(1):49-57. doi: 10.1001/jamapsychiatry.2014.1754. PubMed PMID: 25390793.

2:  Douglas G. Jacobs, editor.  Harvard  Medical School Guide To Suicide Assessment and Intervention.  Jossey-Bass Inc., San Francisco, CA, 1998.

3:  Berner ES, Webster GD, Shugerman AA, Jackson JR, Algina J, Baker AL, Ball EV,Cobbs CG, Dennis VW, Frenkel EP, et al. Performance of four computer-based diagnostic systems. N Engl J Med. 1994 Jun 23;330(25):1792-6. PubMed PMID: 8190157.

University of Wisconsin 2nd Annual Update

I was in Madison Wisconsin for the Second Annual University of Wisconsin Clinical Update.  I reviewed the first conference last year.  For anyone unfamiliar with the conference it started last year as a replacement for the long running conference run by John Greist, MD and James “Jeff” Jefferson, MD.  They were acknowledged again this year for their contributions to psychiatric education.   This is a very good conference because it builds on that tradition.  The actual venue is the Monona Terrace Convention Center on the shore of Lake Monona.  It is an excellent modern facility with only one drawback - they charge for high speed wireless access.  I talked with many psychiatrists there who had attended the previous conferences for a long time.  They bring in speakers who are some of the top experts in their fields for in depth presentations and there is also a strong department at Wisconsin headed by Ned Kalin, MD.  The conference wraps up in in a day and a half and that seems like a very good length for working psychiatrists.  Combine that with very accessible speakers and an excellent course syllabus and it has what I consider to be the elements of a good educational experience.  The other bonus is that I have never really seen an unbalanced presentation at this conference.  The overarching message is that there are a number of interventions, that treatment is successful, and that there is a scientific basis for what psychiatrists do.

I thought I would make a few comments on day 1 and then move on to day 2.

The first lecture was given by Maria A. Oquendo, MD on the Neurobiology, Assessment, and Treatment of Suicidal Behavior.  Aleman and Denys have called for the investigation of suicide as a special problem apart from any particular diagnosis.  She began with a review of the epidemiology of suicide, including the fact that 90-95% of suicides have an psychiatric disorder.  She also discussed the converse of that statement - the vast majority of patients with psychiatric disorders never attempt suicide.  That statement is usually not discussed.  It is a parallel argument to violence and aggression in psychiatric disorders.  It has implications for any care based on dangerousness (threat of aggression or suicide).  She presented an interesting stress diathesis model of suicidal behavior that takes into account clinical features (impulsivity, cognitive inflexibility,  substance use,  family history, poor social support) and neurobiological features (low serotonin, decreased noradrenergic (NA) neurotransmission, inflammatory markers).  Her model links norepinephrine neurotransmission with pessimism.   She cited evidence that included a slide of CRH innervation of NA neurons and behavioral models that lead to NA depletion in animals.   She reviewed some of the evidence of inflammatory signaling related to childhood adversity, the mechanism of interferon-alpha induced depression and markers of inflammation in suicide attempters versus controls (increased interleukin- 6 (IL-6), tumor necrosis factor - alpha (TNF-alpha), elevated microglial cells, increased IL-4 in women, and increased IL-13 in men.  The tentative conclusion is that suicide occurs in the context of a stress response or at least it appears to have the same neurobiology of a stress response.   She concluded with a discussion of public health approaches to preventing suicide.  She had no specific recommendations for how psychiatry fits into that response apart from presenting data that increased antidepressant prescriptions led to decreased suicide rates in Sweden, Hungary, Japan, and Slovenia.   She also discussed specific psychotherapeutic interventions for suicide by name and presented a study of cognitive behavioral therapy that led to a 50% reduction in suicide attempts.   Dr. Oquendo also provided an excellent contrast in how the results of observational studies, meta-analyses, and double blind placebo controlled studies can differ and what biases may be in effect.  In the case of lithium preventing suicidal behavior, most clinicians are aware of the fact that only lithium and clozapine are consider medications that prevent suicide.  In the case of lithium, it turns out that data is from observational studies and meta-analyses but not double blind placebo controlled trials.  The two double blind studies do not suggest that lithium is more effective in preventing suicides than other agents.  She suggested one bias may be a tendency of clinicians to use lithium in people who can use it more safely and that led to fewer suicide attempts.          

I found the presentation on suicide and suicide assessment very interesting.  It is such a broad topic that a single lecture has to pick a focus.  The presentations on suicide that I have seen tend to focus on trying to figure out which people attempt suicide and interventions in those populations.    People with psychosis and suicidal ideation – a common clinical scenario for psychiatrists are generally left out.  It would definitely complicate the presentation at a couple of levels.  There is the issue of what happens to the usual risk factor analysis, especially in the case of subtle forms of psychosis.  Factors that are typically seen as reliable (deterrents to suicide, prevention plans) can be thrown out in that situation since the patient has had a marked change in their conscious state.  That is true whether or not the patient is clinically interviewed or given a structured interview like the CCRS.   In the case of psychotic individuals paranoia is also a risk factor for suicidal behavior.  The paranoia is focused on a particular situation where the individual believes that he or she will be tortured or killed by someone.  They develop a plan to kill themselves rapidly using a highly lethal method before that can happen.   A common scenario is to have a knife or handgun on the nightstand just in case it becomes necessary.  In both of these treatment situations, the preferred course of treatment is to address both the depression and psychosis at the same time.   Past studies of these populations also suggest very high levels of hypothlamic-pituitary-adrenal (HPA) axis activation, consistent with Dr. Quendo's model.

Roger McIntyre, MD followed with Practical Considerations in the Successful Treatment of Bipolar Depression.  There seems to be fairly widespread confusion about the diagnosis of bipolar disorder.  I think it is common for consulting and subspecialty psychiatrists to reverse the diagnosis of bipolar disorder more often than they make new diagnosis.  Dr. McIntyre made that point but said that misdiagnosis is still a problem even in an era of overdiagnosis.   He took the assessment up a notch to discuss the utility and limitations of the diagnostic issues of bipolar qualifiers in DSM-5 ( mixed features, anxious distress) and what they imply for diagnosis and treatment.  He also emphasized the need for time to do an assessment.  He appreciates the fact that primary care physicians may have as little as 6 minutes to make a mood disorder diagnosis but said that even in his specialty clinic he may not know the diagnosis of 25% of the patient after doing a lengthy assessment.  He made this point to illustrate that in many patients a single cross sectional view of symptoms in a clinic appointment is insufficient to make the correct diagnosis.

He presented an excellent graphic showing the DSM-5 continuum from manic to manic with mixed features to depressed with mixed features to depressed.  He also spent a fair amount of time discussing the treatment of comorbid anxiety as a significant morbidity in bipolar disorder.  He presented interesting data on how comorbid medical and psychiatric conditions in bipolar disorder were the rule rather than the exceptions.   His main focus was on metabolic syndrome, obesity, and migraine headaches.  He presented very good graphics on mechanisms associated with these comorbidities.  He made the point that the metabolic abnormalities (much like studies done in patient with schizophrenia who had never been treated with medications) were associated with a number of social, metabolic, and environmental factors.  He suggested that the obesity/major depression and obesity/bipolar disorder phenotypes carried specific risks including poor cognitive performance, anxiety symptoms, and in the case of depression a possible higher suicide risk.   He cited estimates of metabolic syndrome ranging form 20-66% in populations with bipolar disorder compared to a general population estimate of 23.7% from the NHANES III study.  He presented interesting data on the correlation between cognitive impairment in obese and overweight bipolar patients that can be demonstrated in first episode manic patients (obese versus non-obese).  At the molecular level it has been demonstrated that there is a gradient of inflammatory markers between obese and non obese bipolar patients.   He has a published paper that looks at the relationship between treatment response in depression and body weight.  Although he did not speculate on an exact mechanism he suggested there were altered brain systems involved in cognition in many of these patients.

The section of Dr. MacIntyre's lecture included an interesting graphic that had all FDA and EMA (European Medicines Agency) approved medications for bipolar-manic, bipolar depressed, and maintenance therapy.  Both agencies have approved quetiapine for bipolar and only the FDA has approved lurasidone and olanzapine-fluoxetine combination (OFC).  The number of medications not approved in all columns is about the same (4 for EMA and 3 for FDA).  He presented number needed to treat (NNT) and number needed to harm (NNH) analyses for OFC, quetiapine, and lurasidone and in that analysis lurasidone looked like the superior medication but that analysis is for specific side effects.  The NNT was nearly identical for all medications.  In terms of overall treatment he was in general agreement with the Florida Medicaid Drug Therapy management Algorithm.   One of the very interesting points he made during his presentation was that treating and preventing recurrent manic  episodes may reduce risk for Alzheimer's dementia but that is potentially confounded by the effect of lithium on GSK-3-induced tau phosphorylation.         

Lithium Pearls (From several lectures)

1.  The claim that lithium is one of two medications that can prevent suicide is based on observational studies and meta-analyses.  There have been two double blind studies looking at this issue and they have both been negative.

2.  Experts continue to use lithium and consider it to be one of the major treatments for bipolar disorder.  Lithium may provide more benefit to manic prone patients with long periods of stability and a positive family history.

3.  Once a day dosing was recommended.

4.  Lithium can be used in pregnancy given several specific precautions and informed consent issues; including precautions are the time of delivery to prevent elevated lithium levels in the newborn.

5.  Lithium may decrease the risk of Alzheimer’s Disease and minimal cognitive impairment.

   
After afternoon breakout sessions on various topics, the final presentation was by Ned Kalin, MD on the Neurobiology of Depression.  As a point of disclosure I know Dr. Kalin and was his first fellow at the University of Wisconsin back in 1984 and I completed my residency there.  He is a model of the clinical researcher who has seen patients his entire career and also been involved in basic science research.  There were several other department members at Wisconsin engaged in the same balance of clinical and scientific activities.   I learned that he was also President Elect of the Society of Biological Psychiatry.  The UW has always been active in primate research and Dr. Kalin discussed some important ethical and scientific issues about basic science research in non-human primates including the reason for primate research and the changes in standards and research settings over the years.  He has broadened his research over the years to include how depression and anxiety start in childhood and adolescence.   He posted an interesting graphic on deaths worldwide due to violence that suggested suicide was the top cause, followed by homicide and then warfare.  It was based on World Health Organization (WHO) data.  He showed experimental data on conscious regulation of the amygdala.  These interesting studies show that activity in the amygdala can be modulated by cognitive activity that either enhances of decreases the response to the feared stimulus.  The ventromedial prefrontal cortex (vmPFC) and orbitofrontal cortex (OFC) are critical associated areas with activity correlating inversely with activity in the amygdala (high vmPFC and OFC activity correlate with low activity in the amygdala).   Preliminary data suggests that depressed patients fail to suppress activity in the amygdala with vmPFC and OFC activity.  A similar change occurs in the ventral striatum when depressed individuals attempt to enhance their positive affect over the course of an imaging session.  Controls show a significant increase in left nucleus accumbens activity (LNAcc).

Dr. Kalin reviewed the genetics and environmental factors in depression using a graphic that cited 3 of Kendler's papers.  He reviewed the progression of hypotheses ranging from monoamine depletion to altered serotonin neurotransmission to serotonin alteration hypothesis to  stress diathesis to neurotoxins to inflammatory/cytokine theories.  One of the possibilities he discussed was a theory that at least some developmentally based depressions are based on frontal cortical-amygdala substrates that result in increased activity in the amygdala and associated neuroplasticity mechanisms that also lead to increased vulnerability.   Cognitive therapy for depression may strengthen the ability of the frontal cortex to regulate the amygdala.  One of his areas of intensive investigation has bee the HPA axis and its effect in depression.  He reviewed the important roles of CRF both as an endocrine modulator and a neurotransmitter.   He used a Vonnegut quote from Breakfast of Champions as a quick review of HPA axis physiology.  For anyone who had read the book (and forgotten some physiology) it was an interesting reference.   In the last quarter of the lecture he reviewed the issue of stress in separated infants, maternal stress, and adults in human and non-human primates.  The focus was primarily on neuroanatomy, neuropathology, neuroendocrinology and possible treatments that target these systems.  Earlier in his discussion he also posted a graphic on translational neuroscience and how neuroscience findings need to be able to correlate at the clinical level.  A detailed discussion of that approach is available in this article that is available online at no cost.              

The first day in Madison went as well as expected.  Lectures with very high quality content by researcher-clinicians who actually see patients and investigate clinically relevant topics.  Psychiatry taught, researched, thought about, and practiced the way it should be.


George Dawson, MD, DFAPA



1: Oquendo MA, Galfalvy HC, Currier D, Grunebaum MF, Sher L, Sullivan GM, Burke AK, Harkavy-Friedman J, Sublette ME, Parsey RV, Mann JJ. Treatment of suicide attempters with bipolar disorder: a randomized clinical trial comparing lithium and valproate in the prevention of suicidal behavior. Am J Psychiatry. 2011 Oct;168(10):1050-6. doi: 10.1176/appi.ajp.2011.11010163. Epub 2011 Jul 18. Erratum in: Am J Psychiatry. 2012 Feb;169(2):223. PubMed PMID: 21768611

2: Lauterbach E, Felber W, Müller-Oerlinghausen B, Ahrens B, Bronisch T, Meyer T, Kilb B, Lewitzka U, Hawellek B, Quante A, Richter K, Broocks A, Hohagen F. Adjunctive lithium treatment in the prevention of suicidal behaviour in depressive disorders: a randomised, placebo-controlled, 1-year trial. Acta Psychiatr Scand. 2008 Dec;118(6):469-79. doi: 10.1111/j.1600-0447.2008.01266.x.

3: Fox AS, Kalin NH. A Translational Neuroscience Approach to Understanding the Development of Social Anxiety Disorder and Its Pathophysiology. Am J Psychiatry. 2014 Aug 26. doi: 10.1176/appi.ajp.2014.14040449. [Epub ahead of print] PubMed PMID: 25157566.

4: McIntyre RS, Rosenbluth M, Ramasubbu R, Bond DJ, Taylor VH, Beaulieu S, Schaffer A; Canadian Network for Mood and Anxiety Treatments (CANMAT) Task Force. Managing medical and psychiatric comorbidity in individuals with major depressive disorder and bipolar disorder. Ann Clin Psychiatry. 2012 May;24(2):163-9. Review. PubMed PMID: 22563572.


Supplementary 1: I thought it was very interesting that we are still talking about lithium as a very effective medication for psychiatric disorders int he same city that hosted the Lithium Information Center cofounded by Greist and Jefferson and the same location where the Lithium Encyclopedia for Clinical Practice was published.