Yale and OSU Collab To Bring Suicide Specific Care To More People

A phone app that helps cut suicide attempts by more than half sounds like science fiction until you hear the data and the design choices behind it. We sit down with Dr. Seth Feuerstein (Yale School of Medicine) to talk about OTX202, a clinician-supported suicide prevention app developed in collaboration with Ohio State University Wexner Medical Center.  It's built to deliver suicide-specific therapy skills after hospitalization and other high-risk periods.

We walk through why proven suicide interventions often fail to reach people who need them most.  We also dig into stigma and the “why would they do that?” trap, using a striking medical analogy: suicidal crisis as an arrhythmia-like state of the brain.  Dangerous?  Yes.  Treatable?  Yes.  Finally, we get practical about implementation and where artificial intelligence may fit next, with ethics and safety front and center. If you care about mental health, digital therapeutics, and evidence-based suicide prevention, subscribe, share this episode with someone who works in care, and leave a review so more people can find these conversations.

Transcript

Meet OTX202 And Why It Exists

SPEAKER_03 0:04

Welcome to our latest episode of Voices for Suicide Prevention. As we like to say, our conversations are real talk, real honest, real life. I'm Stephanie Booker.

SPEAKER_00 0:14

And I'm Scott Light. We are talking about a breakthrough today in suicide prevention. It also, Stephanie, as you well know, it has some hometown roots. It is a collaboration between OSU's Wexner Medical Center and Yale's School of Medicine. Dr. Seth Fewerstein from Yale joins us right now to talk about it. Dr. Fuhrerstein, welcome to the podcast. It's good to see you.

SPEAKER_01 0:39

Thank you for having me, and it's great to spend the time together.

SPEAKER_00 0:42

Well, as we understand it, teams from both schools developed a phone app designed to deliver suicide-specific therapy after a hospitalization. So the app is OTX202. We've got to ask you about where that came from, but we'll get to that in a little bit. Tell us, let's start broad. Tell us about the app and what it does to help.

SPEAKER_01 1:03

Sure. Well, you know, the app really grew out of some work done by a handful of researchers around the country who were each running separate uh research and clinical programs on how to reduce suicide attempts, uh how to reduce suicidal thinking. And believe it or not, conversations about it started more than a decade ago. Uh, there was this human-delivered set of uh interventions and exercises that essentially were unscalable. Uh studies showed multi, you know, over and over again that if super specialists were delivering them, you could reduce suicide attempts by more than half, you could reduce suicidal ideation significantly, but it's like a subspecialty, and you really can't uh adequately train people. It would take a typical psychiatrist or psychologist several months full-time with one of these researcher clinicians to really learn the therapy. Um, and and it's just not feasible and not scalable. And so there were a series of conversations. Uh I had done a large amount of work scaling mental health interventions using software. One of the leading leading suicide uh prevention experts and researchers happens to have been at Ohio State, right? So uh that that was a you know how it started. Like, how can we get the right things into the hands of clinicians and patients so that we can actually uh bend the curve and reduce risk and improve outcomes for a shockingly and unfortunately common uh situation? Uh more more common than most people think, actually.

SPEAKER_03 2:46

Is the app geared toward a certain demographic? Um is it for anyone to download? I mean, how how is that delivery system and and who is it being delivered to?

SPEAKER_01 2:58

Yeah, it's really designed to be used in collaboration with a clinician. And so it's not for general public use. Um it's really the the kinds of individuals who it's designed to benefit is a diverse group. Really, anybody uh who has a history of known risk uh for suicidal thinking or attempts. And so uh it's not something that somebody with no history would probably benefit from. And it's really designed as a tool. This may sound uh counterintuitive, but a tool to bring the clinician and the patient closer together uh around this particular um and incredibly deadly problem.

SPEAKER_00 3:40

It's also a little serendipitous here that we're talking about this.

New Studies Show Rapid Improvement

SPEAKER_00 3:44

We're we're recording this episode and just found out from you, Dr. Fieberstein, that um you have some data that has has just come in uh regarding research and things like that. So we just want to tee you up from that. Um, what do we know? What's the latest data that you have?

SPEAKER_01 4:02

Yeah, I mean, I'm really delighted that uh again, I actually wasn't directly involved in this study other than having co-developed the software. But uh at Ohio State, um Dr. Craig Bryan led a team that um investigated the use of the app in collaboration with clinicians, seeing college students um there, and found really remarkable uh rapid and sustained reductions in suicidal thinking. Uh it was completely safe to use it, and in fact, much safer for the patients uh as compared to other groups that have been studied. Uh, very rapid, very quick reductions in ideation and extremely strong feedback on what's called usability. Did the did the individuals like using it? Did they find it engaging? And the answer was yes, the vast majority went on to use the whole thing. And in in populations of individuals who have suicidal thinking or attempt history, actually engagement in care is is often a challenge. And uh these individuals use the app extensively and had phenomenal outcomes. That actually just published uh three days ago in a really, really nice study. Uh that that's a follow-up. Uh it's sort of a separate study from another large study that was published several months ago showing about a 60% reduction in suicide attempts across a very diverse adult population. Um, really, really pleased to see that. Uh, really, again, really compelling data that it's completely safe and and quite effective uh to use this as part of the care that these patients are receiving.

SPEAKER_03 5:42

Did it shock you in any way? Or we were like, yeah, this is what this is why we developed this app?

SPEAKER_01 5:49

I mean, we were confident it would have a positive impact. Uh, I think one of the interesting things that's that's that you know we're happy to see is that it seems to be having positive impact across multiple different types of ways to look at at these these individuals and how they look at themselves. Uh there were scales around how does the clinician look at, you know, think they're doing, and did really well based on how the clinicians thought these individuals were doing. Uh, how did the patients report they were doing and the patients reported they were doing really well? And then how did the objective data on things like attempts and scales that measure ideation show? And again, on those scales, people did really well as well. And that's really great to see. And this was really in addition to all other treatment. So they were getting everything. They were getting talk therapy that they would otherwise get, they were getting uh medications, they could get electroconvulsive therapy, they could get TMS, they could get really anything and everything. And this was just in addition to that. Um, and so that was pleasing to see that it was having a significant impact, an impact that was, you know, right in the sweet spot of where we've seen other studies when humans deliver all of these exercises, uh, because that's what we wanted to see was that we could at least get some of that

Making Suicide Care Scalable

SPEAKER_01 7:05

impact. I think at the end of the day, nothing really replaces the very best suicide, what we call suicidologists, but there will never be enough suicidologists for all the people that need the care. And at the same time, they will not be distributed in the places where these patients and individuals uh show up. You know, most people don't realize that most of the hospitals in this country don't even have a psychiatric unit, let alone a specialist in treating suicidal patients. And so um, from many different directions, it's a real access problem and one that is is probably not going to be solved the old-fashioned way.

SPEAKER_00 7:41

What do we do with the information that you just shared that is that is, as you mentioned, just uh days or weeks old from from again when we recorded this, plus that 60% number um from Well, I should I should say it was really about a 58% reduction, not 60%.

SPEAKER_01 7:58

I don't I'm a data-driven guy, and so I don't want to exaggerate. We found about a 58% reduction in attempts in that prior study uh per patient per year, per patient year, basically. So for every year of patient time, uh, we saw about a 58% reduction in the number of attempts.

SPEAKER_00 8:16

So besides having conversations like this, getting the word out, as you said, we've got to educate people about this. Where do you take this data from here again to make it uh a ubiquitous part of the conversation when it comes to mental health and suicide prevention?

SPEAKER_01 8:31

Conversations like this are really central, uh, as well as conversations with clinicians. Um ultimately, as I said, we we really only want this to be used and it will work best with clinicians. And so uh getting the word out among people who may know someone who could benefit, getting the word out among clinicians. Um, we we have plans to start doing more of that, but we also want to do more studies, publish more data. Uh, we there's another large study underway in the military. Uh again, I'm not running that study, but I understand it's going incredibly well. Uh, that's you know, we've done sort of that first study, the one that you mentioned, the 60% number from that I said was 58. That study was done at six large medical centers in the U.S., all across the country with a very diverse patient population in diverse geographies and cities. The next study was in college students, which is a real uh important population. I think everyone's probably aware that in the military and veteran population, suicide's a big issue. This the large study that's underway in the military is actually funded by the military. It's being used in primary care, again, with clinician support. And I understand it's going very, very well. Uh, and I'm hopeful that that data will get published uh soon as well. And so, you know, the more data we can collect on different subpopulations, uh the more the scientific and academic community. And, you know, one of the unfortunate things is even in the clinical community, among primary care, among psychiatrists, psychologists, and social workers, a lot of people don't want to ask about suicide because they don't have good tools to offer their patients. And we've seen this over and over again in healthcare. Cancer is a fascinating example where if you look into the history, if you go back 50 years, no one wanted to talk about cancer. That's right.

unknown 10:25

Right?

SPEAKER_01 10:25

They called it the C word, and there's even different television shows.

SPEAKER_00 10:28

Yeah, the big C. Yeah.

SPEAKER_01 10:29

The big C. And that was because they weren't good treatments. No one wanted to talk about it. Maybe inside your household, people knew, but your friends, your family, your co-workers, you didn't discuss it. One of my hopes, and our entire team and collaborators' hopes, is that if there's a good tool like this out there, people will talk about it more and we will get to a good cycle where there's more awareness, more accessibility, and more of an embrace around the fact that actually the suicidal state of the brain, it's not that different than the cardiac arrhythmia state of the heart. It's just something that happens. We've got tools that we can use to reduce the risk, and we should focus on reducing the risk and not worry so much about the why or whatever else isn't really that relevant.

Suicide Mode Explained With Heart Analogy

SPEAKER_03 11:15

I think I'm I'm kind of fascinated, um, Dr. Firestein, that you're seeing like a very diverse population, uh, college-aid students, um age maybe not a barrier. Is that a unique way to be able to help people who are suicidal? Because I I think that there are there are so many different reasons that someone um, you know, has those struggles and those challenges as there there are, you know, birds in the sky. So I I'm curious, you know, is this are you surprised at being able to have an effect at at many different demographic level?

SPEAKER_01 11:57

We're actually not surprised. And some of this comes from a better understanding of the suicidal state of the brain, something we call the suicide mode. Um, I think historically there's been a tremendous amount of prejudice and bias against mental illness generally and suicide specifically. And I'll say a few things to make the point of how it's not that different. Like we talk about suicide attempts, suicide and so it's like, why would that person choose to do that? But really, that's it's not a choice. It's like saying, why would that person choose to have a cardiac arrhythmia? Right? A cardiac arrhythmia and suicidal state of the brain, they're both somewhat spontaneous periods of risk for sudden death. They're not that different. And if you ask people who've had a suicide attempt, most of them will say, I didn't want to die. My brain just didn't see another step forward. And in that way, it's really a lot like an arrhythmia. They're not choosing it because they don't see another option. Uh, and it results from various traumas to the brain, not unlike the way traumas occur in the heart. And so that's true across the age ranges. What you see tragically in suicide is that it's the second leading cause of death in people from 12 to 25, third leading cause of death in people from like 25 to 35, and fourth leading cause of death from 35 up until about 60. And it's basically a leading killer throughout our entire lifetimes, including over the, you know, over the age of 60. And so, because not unlike other diseases, it can strike anyone at any time. And it really isn't about choice or it's really like how do we look at this objectively, remove the prejudice and say, okay, what would we do in the case where the person's brain might end up with an arrhythmia-like state? How can we keep them from getting into that state? How can we train them to do the things they need to do to get out of that state? Uh, or to seek help when their brain isn't functioning properly. To give you an example, listeners can't see us, but all of us are sort of in those very high-risk age ranges I I gave. And if I said to both of you, even after the statistics I gave you, what do you think the chances, if what are the top three or four things you might die from in the next year, you probably would not say suicide. Right, right. But I just told you it's actually one of the top things you would die from. And that's because when our brain is functioning properly, we can't imagine that we'd end up in that suicide state. But if you get enough trauma, and that could be physical trauma like a traumatic bean injury, it could be drugs of abuse, it could be another disease of the organ like Parkinson's or Alzheimer's or schizophrenia or major depressive disorder. Um, the same thing that that causes stress on other organs can cause stress on the brain or and vice versa. And you can end up in that any organ system can get overwhelmed, including the brain. And it's just a question of getting out of that state and getting back to more normal functioning.

SPEAKER_00 14:48

Stephanie and I recently had a conversation with a gentleman who uh works in, used to work in the construction industry, and now he is um he has a uh uh pastoral background uh as a youth, youth pastor, youth minister, and now he's formed his own company to where he's going out and talking to two construction companies, talking to those chief safety officers and and and about what's going on in the end in that industry. I thought about that when you when you went through a couple of statistics and this gentleman Paul shared with us, I had no idea that in the construction industry there are five times as many suicides as there are construction fatalities. So I I just think about this app and all the I don't want to say subsets because that makes it sound impersonal, but but uh you guys know what I mean by that. The fact that we could go to the construction industry, go to young people, go to the military, go to college students and say, hey, we have something here that's working. I would that's that's a powerful thing.

SPEAKER_01 15:50

I we hope we hope so. I think, you know, I'm a psychiatrist by background. I worked in lots of emergency rooms. Um it was not very effective to try to screen and figure out who was at risk, but we actually know who a lot of those people are. They either have a specific history of suicidal thinking or an attempt or a family history. And I think when we have tools available, it's much more likely that people will talk about it. And and, you know, this software, this app, it's really about empowering the individual with their own self, self-skill building so that they kind of embrace the fact that they can, in fact, do something. You know, we've done this in other areas that lead to death. You know, one of the ones that everyone makes fun of is stop, drop, and roll in the movie theater. Like, I don't know if you've ever seen that. It's like, what do you do when there's a fire? People used to die in fires in movie theaters, but you know, they remember they used to have like candles and things lighting behind the screens. You know, stop, drop, and roll, get under the smoke, roll to the back, don't yell fire. There are these structured things, and that's a very simple version that if we can practice them and learn them, we actually start to distribute them and they can really save lives. CPR is another great example, right? And so, um, and of course, you see on TV people learn how to do codes in the hospital and what to administer in order to bring people back from potentially life-threatening situations. In this case, we're hoping the app will help people feel more comfortable doing things in advance and during those episodes that can reduce

Why AI Is Not Yet Inside

SPEAKER_01 17:21

risk.

SPEAKER_03 17:21

One of the topics that we have been discussing here uh as well as with other uh advocates around the nation is artificial intelligence. And I don't know, um I'm hoping maybe you can lend a little bit more information about the app. I know you said that this is in combination with clinician help. Um, are we looking at AI being part of this app, or is it is is that not an issue with this app?

SPEAKER_01 17:51

Yeah, we are not using artificial intelligence today in the versions that are being studied. We are actually working on the next generation of products where so so we have certain things that we know work broadly.

unknown 18:03

Okay.

SPEAKER_01 18:04

Uh but like so many things, we are hoping to learn over time what works more specifically with different people. Uh, there are so many variables that each individual has. And so we do believe there will be newer versions. We are working on that that incorporate ethical and appropriate levels of artificial intelligence. Again, really around bringing the clinician and the patient closer together, providing more context, more information about what's working and what's not working and what can work for them. And so, right now, artificial intelligence is not a part of it. Um, we believe it's inevitably going to be important to get even better than the 58% reduction in attempts, even better than the dramatic reductions in ideation that we've been seeing. Uh, but you know, stay tuned for that. Right, right.

SPEAKER_03 18:50

And we and I appreciate uh I heard you talking about making sure that we're we're looking at the ethics as well as the responsibility that you know that innovation has to be able to help support those who are most at risk. And some of the things that we're seeing on other uh platforms and so forth is is not always the case to be able to help people.

SPEAKER_01 19:13

Yeah, I mean, it tragically unrelated to our work, uh, there's been coverage of very some very bad outcomes where artificial intelligence um is involved, and and there's just a lot of movement in that area, and it's it's unfortunate. I wish I could change that. I'm not in a position to do that.

SPEAKER_00 19:31

Right.

Challenging Myths About Depression And Suicide

SPEAKER_00 19:32

What surprised you about the development of this app? Kind of lift the curtain for our listeners here, take us behind the scenes. What was what was the surprise or maybe the uh a really big challenge um in developing this app?

SPEAKER_01 19:46

So one of the things that was I'm a cynical optimist or an optimist, I guess, depending on which of my colleagues you you'd speak to. I have a long history of using software in mental health care, um, even going back more than 15 years. And so I am used to concern and pushback around incorporating software. I understand why people get anxious, but again, it never ceases to surprise me in various moments. One of the things that was an aha moment for me that I try to explain to people is how much prejudice and bias there is around the topic of suicide. And and so for I'll give you one really common example. Well, someone had a suicide attempt, they must have been depressed. Actually, most people who have a suicide attempt do not have major depressive disorder. Just like most people who have a cardiac arrhythmia do not have a previous heart attack, right? Um, and so like heart attacks increase your risk of an arrhythmia, but you know, one does not necessarily lead to the other. And so this idea that you would focus on suicide as its own clinical syndrome rather than the related disease that you think is related to it. But the truth is, most people uh do not have major depressive disorder who attempt suicide. Maybe about a third do. I mean, it's it's hard to get great data. And so that's one of the things that that continues to come up is is is this its own thing to treat? And I often go back to the arrhythmia example because I say, well, like cardiac arrhythmias are not really like a disease, like we don't, they're not like heart attacks. We think of it as a as a syndrome that's treatable because we have treatments for it. But but if you go back prior to when we understood it and had treatments for it, people used to think you were the devil was in your soul when you had an arrhythmia. They thought you had some sort of other uh spirit inhabiting your body, or you had done something wrong. Like it's not that long ago that that's what people thought when the heart would get into these arrhythmia like states. And I think, you know, hopefully we're not too far off uh with changing suicide in that same direction. But there really were a lot of people who didn't. I still talk to and they're like, but why wouldn't you treat depression? And I point out to them there's lots of antidepressants on the market, and they've basically all failed to show a reduction in suicidality. In fact, a lot of them have a warning that they may increase suicide risk. And I think, you know, there's a lot of discussion about that. We won't get into that here. Um, but you know, so I think that says a lot about the link. Yeah, if you have major depressive disorder or any other disease of the brain, it increases your risk. So that's one of the surprises, is that it's going to take a lot of work to remove that prejudice, uh, I think from the system.

SPEAKER_00 22:33

I think one of the aha moments for me, and and really just doing this podcast uh the last several years is your uh comparison to cardiac arrhythmia. That that clicks for me.

SPEAKER_01 22:45

I use the heart as an example for several reasons, but I could use, I could talk about the liver or the kidney and I'm happy or the lung. You know, all of our organ systems basically had excess reserve capacity. So, you know, you'll you'll know someone who's a smoker and they'll smoke for years and years and years, and then boom, all of a sudden they're suffering from emphysema. It's not that they just had problems in their lung, they have excess lung capacity. And over time, the traumas on the lung eventually exceed their ability to absorb it. You see that in liver disease, whether it's from hepatitis, from a virus, or from drinking, damage is happening, they seem okay, and then boom, they're not okay. It's not that all of a sudden something different happened. And I think the brain is similar. There's a there's a lot of reserve capacity in most people, and the various traumas and things that impact the brain all increase the risk of this arrhythmia-like state that that can, you know, is usually temporary. And I like those analogies for several reasons. One is it I think it helps pull people away from this idea that like the brain is different. We think it's different when it's functioning well because our brains are the thing that like kind of digests the world for us in terms of what's happening, but it really isn't that different when you look at the data. And this, so someone is that comfort around like this is a disease, we should think about it objectively, and we should try to help people and not get caught up in, well, why would they do that? It's like, let's not focus on why, let's focus on how we're gonna reduce the risk. And the second thing is in we've we've had such a huge impact in these other organ systems. Like, if you look at heart disease and death and arrhythmias in death, the way we think about and structure our interventions in those organ systems has had a huge impact on saving tens of millions of lives. And rather than start from the point of like, well, the brain is just different, I'm like, well, we've saved a lot of lives with lung treatments, we've saved a lot of lives with heart treatments, we've saved a lot of lives with kidney treatments, we saved a lot of lives with liver treatments. Maybe there's something to the way we frame those interventions and those diseases. It's not perfect. I want to be holistic. I want to think about humanity and the human, but I also want to stop the deaths that are that are avoidable. And like maybe we should start to think about those models and how we can really impact risk and death. It's not perfect, but it seems to have worked in a lot of other organ systems. So why not try to use some of those analogies for suicide?

Next Steps And How To Get OTX202

SPEAKER_03 25:09

So as we move forward for the future of suicide research and prevention, and now that we have the data backing up how OTX202 is working so far, what do you see coming down into the near future related to this field?

SPEAKER_01 25:28

We anticipate a lot of progress on the work we're doing. You know, for us, this is just phase one. Uh the app is really a starting point. Uh, once we have increased distribution and use uh over time, we want to continue to learn, continue to improve what's available, uh, continue to evolve. You mentioned artificial intelligence. We think that's inevitable, but we also think uh there'll be different versions over time, potentially, or different ways people leverage the tool. For instance, uh one of the nation's leading experts in treating suicidal patients would like to use the app so that he can see more patients. So rather than it just being a tool for people who are not suicidologists, he can use it and see three or four times as many patients because so many of the exercises he spends his time doing are actually in the app. And he can just leverage the app for the practice rather than do it himself, as one example. Another is some different versions. We have a version for teenagers. Uh, there's a fairly ambitious multi-site clinical trial going on right now. Uh again, we don't see all the data, but it seems to be going quite well. Uh, and so we're hoping that data will be available in the next year or so. Uh, so we see some slightly different versions. And then, you know, it's interesting, antidepressant treatment really came out into the open with Prozac in I think 1987 it was. And what you saw after that was an explosion of research and work into what are the different types of antidepressants for different people. Um I think, you know, we hope that the same kind of thing happens, that by by bringing tools out there, people are more willing to talk about it, more willing to explore ways to have different um levers to take advantage of, whether it's different versions for different people, different ways people use the tool. Uh, we think all of that will occur. And I and like I said before, I think artificial intelligence will become a powerful layer uh to what we do, um, but ultimately being used to bring the patient and the provider closer together and to have better impact, better engagement with each other uh rather than replace that relationship.

SPEAKER_00 27:40

Dr. Fuberstein, last question. Um, and for your background, we have 88 counties in Ohio and about 75 or so county suicide prevention coalitions doing that ground level work you know every single day. It is very possible after this podcast uh goes public that that Stephanie and OSPF, all of us, could get some uh uh uh text, emails, or phone calls saying, How do I get this app? Where do I get more information? So what do we tell them?

SPEAKER_01 28:10

Uh well, there's certainly the team at OSU. Um, my you know, my email address is on the Yale directory. People can reach out uh to me via my Yale uh email address and we can talk about what options or opportunities are available. Um, you know, we're in some discussions like that now, and you know, we want to make sure that this is used properly, uh, distributed thoughtfully, and that people's expectations are in line with what we know works rather than uh what they may think works. And so I'm happy to have those discussions about how we might collaborate. Absolutely.

SPEAKER_03 28:46

Dr. Fearstein from the Yale School of Medicine. Thank you so much for joining us today and talking about OTX202, and then the new app that you have helped to develop along with the Ohio State University.

SPEAKER_01 29:00

Thank you for having me and thank you for your work. Really fabulous.

SPEAKER_03 29:03

We also appreciate our listeners. Thank you as well, because when you listen to our episodes, you're breaking stigmas, breaking barriers, and you're caring about mental health and saving lives. This is Voices for Suicide Prevention, brought to you by the Ohio Suicide Prevention Foundation.