BiM #1 - Suicide Prevention - Feat: Lauren Weinstock, PhD

Episode 1:
Topic: Suicide Prevention 
Script editors: Madison Pomerantz, MD & Camila Cosmo, MD MSc PhD
Senior editor: Brian Theyel, MD PhD
Co-EIC: Tracey Guthrie, MD & Camila Cosmo, MD MSc PhD
Guest: Lauren Weinstock, PhD
Host: Tracey Guthrie, MD
Co-host: Camila Cosmo, MD MSc PhD
Video/audio producer and editing:  William Cosmo, MBA

Transcript

0:04

Welcome to Bear in mind the Brown Psychiatry podcast. Clear Current content about mental Health. I am the host. Dr. Tracie Guthrie, Psychiatry Residency Program Director and coeditor in Chief. And I'm Camilla Cosmo, Chief resident and editor in Chief. First, a content warning. In this episode, we'll be talking about sensitive topics, some of which you may find triggering. If you were having suicidal thoughts, please contact the suicide and crisis Lifeline. Call or text 988 or access 988. Lifeline Talk. Our only purpose is to provide education and information. Our content is not to be considered medical advice. Suicidal ideation or thoughts of suicide is a common experience that affects many people. Every year, more than 700,000 people die by suicide, which means that they intentionally end their own lives. In the past 20 years, the number of suicides has been going up. In 2020, one person, the United States died by suicide. Every 11 minutes is estimated at 160 million people worldwide, and 12.2 million people in United States have suicidal thoughts every year. Suicide is a serious problem that affects people of all ages, and it can have a big impact on families and communities. To help prevent suicide, it is important to use a variety of strategies, including efforts at the individual community and population levels. So to talk more about the serious problem. We invited Dr. Ladan WINESTOCK, clinical psychologist and professor of psychiatry and human behavior at the Brown University, where she conducts research on suicide prevention. Welcome back. The lifestyle. Hi. Thank you for having me. It's a pleasure. It's a pleasure to. Based on data from the American Foundation of Suicide Prevention, 78% of adults interviewed believed we can do more to reduce suicide risk. Dr. Weinstein, what might doing more look like? I want to start by saying that we are already doing a lot and the efforts that we make are already making a difference. And the science, the research that we're conducting is teaching us about how to best prevent suicide. With all of that said, we can absolutely do more. I agree with the poll respondents to the AFC Peace poll, and I'm struck by the introduction that was just provided about the individual, the community and the population level, because that's exactly how I think about suicide prevention and what we can do more. And I think we can do more at each one of those individual community and population levels. So thinking of it as a multi-pronged approach. We could think about first at that individual level, which might also be community, I guess now that I'm thinking about it. But I think we could do more to educate the public like we're doing now in this podcast, providing people with tools to talk to loved ones and friends about suicide and helping them understand how to navigate the system, to support getting access to care for those people, the people that they love and care about. I think we also can do a better job in terms of implementing and disseminating evidence based practices in our health systems. So things that we know work in terms of risk assessment and treatment and prevention prevention practices, not just in our health systems, our systems of care, but other systems that also touch people who might be at risk for suicide. And those are really any of our systems in our communities, such as schools and universities. I do a lot of work in jails and prisons and think that's another area that we can really focus our efforts on. And there's also a lot of work being done in faith based settings. So, for example, I have a colleague, psychiatrist Dr. Sidney Hankerson, who's at Mount Sinai in New York City. He's been doing a lot of interesting work on suicide prevention in black churches. And so touching on those systems and disseminating and implementing what we know works, I think would be taking our suicide prevention efforts to another level. At the last the other level I think is really important is advocacy and some of what we're struggling with right now in suicide prevention in our country is our limited infrastructure and capacity to help people who need it. So we have wonderful systems of care. We just don't have enough of that to to reach all the people who need that support. And so ways that we can advocate at the local level, the state level, the federal level for funding to build out that infrastructure and increase the supports was really important. I think just as one example, the 998 crisis line that was just very recently established, the federal government put a lot of resources into supporting the states in implementing 980, which went live last July. But for sustainability, it's the state's responsibility to maintain nine, eight, eight moving forward. And a lot of the states are struggling to figure out how to build that into their budgets. And so we can, as advocates for suicide prevention, work with our local politicians and legislators to try to support those policy changes that can help support suicide prevention. Indeed, And talking a little bit about warning signs for suicide, what should people look for? So so taking a step back, there's not one cause of suicide. So suicide is multifaceted and we know that suicide there's no again, no blanket rule around who who will die from suicide. But we know that it most often occurs when stressors and underlying health issues come together to create an experience of hopelessness and despair for an individual when people feel that there's no way out. And so things to look for with respect to warning signs, if you're coming into contact with somebody and you're concerned about them, would be sudden changes, things that appear different than what you're used to seeing in that person that loved one, that family member friend, that patient you're working with as a professional. And I think it's important to think about warning signs as far as signals that something might be wrong, but not necessarily red flags potentially, but not necessarily something to panic about in the moment either. These are just signs to indicate that that is a moment that would be good to reach out and offer support. So with that said, I think about things that people you might want to attend to with respect to what someone might be saying, what they're expressing to you, language about hopelessness, language that life is not worth living, language that they don't see a future for themselves. Things of that nature would be some red flags or warning signs. I also think that change in behavior is an important thing to attend to with respect to warning signs. So if somebody is withdrawing from their activities or their life, if they're using more alcohol and drugs than is typical for them, if they are giving away possessions, which is a warning sign, I think some is a little bit more well known to people, but not always something that we see if somebody is a little bit more agitated or hostile, that could be a sign as well. And also somebody sleeping a lot. Again, just that withdrawal and isolation. And then finally, there's kind of the emotional piece of somebody is if you're getting you're noticing a sudden change in how somebody appears to be feeling, if they're extremely sad, anxious, they're expressing feelings of shame or, again, feeling alone in the world. Humility, passion, those types of feelings, those are those are things to pay attention to. And again, those red flags that might indicate that support and outreach to that person would be helpful. I think as much as we talk about warning signs, it's also important to remember protective factors as well. And so just remembering that access to care and support is an important protective factor. Feeling connected to family and community, feeling a sense of belongingness can be really important. Having abilities to problem solve difficult life experiences can also be protective, and also limiting access to means that somebody could use to harm themselves can also have a protective role. So if I could sort of follow up about a couple of things that you said there, because I think it's important for the listener to know, because I can imagine a lay person being out in the community listening to this and saying, I am worried about someone, but I don't feel like I could do anything right and so I think we want to try to give people permission to do exactly what you said, call someone, check on them. What would someone say? What would you recommend someone even say when they just pick up the phone and there's somebody you're worried about? So this isn't an expression I made up myself again, it comes from the American Foundation for Suicide Prevention. But one of their recommendations is to, quote, have an honest conversation. And I really love that because what what that means is that you're opening a door to a person to give them an opportunity to share what's going on in their lives and asking somebody about suicide. Does not make them suicidal. Right. But asking somebody about suicide gives them an opportunity to let you know what's going on and if they need help. And so some of the recommendations, ones that have been shared with respect to what to say or what to do would be to talk to that individual and private, give them a private and safe space to share. You know, if you're out in Starbucks or something like that, that might not be a place where someone feels the most comfortable. Leave a lot of room to listen. Listening is so critical and important, expressed that you care about them. And you're asking because you're coming from a place of caring and concern. And also and this is hard for a lot of people to do, but to ask them directly if they're thinking about suicide, just saying the words, we don't need to use euphemisms or talk around it or dance around the topic. If we're concerned that somebody might be thinking about suicide, we should ask them that. And in my experience, people will tell you when you do other things that can be part of the conversation, could be sharing with them what you know about treatment and how treatment can be helpful for them. So help or offering to help connect them to treatment as part of that and working with them to connect to nine, eight, eight, for example, or if it's not an immediate emergency talking through, how do you connect with a treatment provider, whether you have a treatment provider or whether we need to set that up for that person and staying with them while they go through this, if you can, and if whether you can or you can't. Also following up with them later, right. So that they know it's not just a one time expression of concern that you're there for the long haul. So you mention something to us in terms of like helping people to get access to treatment. And this is something that I'd like to discuss a little bit further, talking about access to care. What are the main challenges that people face nowadays to get to the help that they need and how can we help with that? So so I referenced this a little bit before, but I think from my opinion, from my perspective, the biggest barrier to accessing care right now is just the limited capacity of our system, right, to support that. So we have a situation in which right now there is quite a large need for mental health supports and services and there are not enough providers to go around. So we have people who are doing the difficult work of calling around, looking for care and being met with brick walls in many ways as sad and discouraging as that is, that's the state of affairs right now. And so we have waitlists. We have even when people go to emergency departments, there can be long waits in the E.D. And so finding you know, you didn't ask me about overcoming that, Did you ask me about overcoming that? Yes. This is something that. Again, I yeah, I think it's it's a policy issue. I think we need to advocate with our politicians and the people who make decisions about funding for our supports to really invest in growing our mental health infrastructure. Because, again, we have people who are professionally trained to provide support, but it's they can't do it alone. We need larger networks of support for people. So I really I, I am not I have not always been a very political person in my life, but I think as a suicide prevention researcher, I've become more political simply because I do see a lot of the answers to these problems as being policy, right? Policy related? Yeah, I think many of us in health care see ourselves in a more advocacy role than ever because we really are putting up against that. But I think your point is extremely well-taken that even the community just being a member of the community and caring about this, you have access to your policymakers as well. And you can absolutely call them and say this is a concern of mine. And and I want to share that. And I think we need to pay more attention to that. I do think that the voices do matter. Yeah. So I wanted to ask you about social media because that's another big issue that people often worry about. So do you do you think or is there research to suggest that social media platforms like Tik Tok and Instagram increase the risk of suicide? So this is an area I don't have as much expertise in, and I know there are people who study this directly. I do hear a lot of complaints from family members, from patients, from people in the community where there's a lot of effort and energy focused on social media being the cause of suicide. And like I said before, suicide is not caused by any one thing. What I understand from the research on social media and suicide and this is, I think, largely been conducted with teenagers, which makes sense because we think of teenagers as being especially connected to their phones these days and such. And I'm a parent of a teenager, so I see it myself. But I think to the extent that social media provides an outlet for social comparison, feelings of exclusion and most importantly, bullying, I think there is some evidence that it can contribute to risk for suicide, particularly when it's in combination with those other risk factors and warning signs that we know about. So it's not a great recipe, right, for somebody who is already feeling anxious or depressed or struggling socially to go online and see that their friends have gotten together and excluded them from the invitation. Right. But then there's the other side of the coin. So it's a little bit more nuanced where social media may also have a protective effect for some people in that it can connect people and bring them together. And this may be particularly important for people who come from marginalized groups and people who have experiences of isolation and discrimination in their communities through social media. They have access to a world of other people who are like them and with whom they can connect. And that can be a positive buffering experience for somebody who feels all alone, but then goes online and realizes, Oh no, there are all these other people just like me and I can connect with them. So. So I think social media is something we have to monitor and pay close attention to. But from what I understand, at least from the science, is that it's not all good or all bad. Right? Right. And we heard like we hear this from many parents, the concern about like some trends that we see, for example, Tik Tok, like trains of self-harming or like videos of people just like encouraging suicide or even like something so extremist, someone like trying to kill themselves and recording that. What are your thoughts about the backed off of videos like this in trains like this for the people that are like consuming that well? Well, I, I think in general any type of content that's being shared publicly that's encouraging people to engage in self-harm, providing information about how to do that, I think it really is the responsibility of the essentially the businesses that operate these platforms to wipe that out. I don't think there's any place in social media or it really anywhere in our society for that. And we know that talking about talking about suicide is really important and we shouldn't stigmatize that discussion. But the way we talk about suicide matters and makes a difference and an overflow bias on methods, for example, or kind of like a sensationalized way of talking about suicide, we know we know can have harmful effects for people. When we talk about how people can get help for suicide and what resources are available to them, we know that can be helpful for people. So I am deeply concerned about anything that is on the Internet that supports a sensationalistic view of suicide or that is encouraging people to engage in that behavior or providing details about how to do it. Yes. And for those who who may be listening, who are feeling unsafe right now or concerned about a loved one, what steps can we review right now that can be taken to help themselves or the person that they care about? Yes, If somebody is concerned for themselves, there are resources available and I would start I think I would start with 98. It's the mental health crisis line. It is designed to support people who are struggling with suicidal thoughts and behaviors, but also people who are having other stresses and struggles as well. And what's wonderful about it is that the people who answer the phone are trained to discuss these issues. They're trained to provide support, and they're non-judgmental by design. That is what the support line was designed for, and that's available 24 hours a day. There's the crisis text line, if I know now a lot of people don't like to talk on the phone and prefer text messaging. We have a text messaging option for people and you have immediate support and care and what I tell my own patients when I encourage them to use these supports is that the people who answer the phone are not going to be shocked or surprised at all by what you say. They're used to talking about these issues and they're here for you. That's that's why they're there. I would also encourage people to seek support from their their loved ones and the people who they can what they identify as being supportive. So identifying some people in your life, you know, will be there for you and feeling comfortable sharing with them can be very important as well. And using your your support network as a resource to help you is going to be important. And then if you have a primary care doctor, you have a therapist, psychiatrist and any other treatment provider who you might be working with, you can also use them as a resource to let them know, Hey, I'm struggling. Things are harder for me right now than they've been before, and maybe that means increasing the amount of contact you're having with your health care providers or receiving a referral to somebody new could be really important as well. Okay. We have two last questions for you before we wrap up. This has been so helpful. Thank you. I want to go back to what you said about access to, you know, things that could harm people. I want to speak specifically about firearms. Yes. And again, in your model of we shouldn't avoid talking about difficult things, we have a complicated relationship with firearms in this country. However, if you are a gun owner or are not a gun owner, but you're a responsible gun owner, what should you be doing? If a, you know that someone has a weapon and that they're not feeling safe or too you are a gun owner yourself and you're not feeling safe, We should we should address that particular issue. We should and we do in suicide prevention. That's a really important part of a conversation that we have. We do. There's a brief intervention called the Safety Planning Intervention. It's a one session intervention where a clinician and a patient work together collaboratively to develop a safety plan. And part of that safety plan is steps to make your environment safe. How do you put distance between yourself and things that you could use to harm yourself? In a moment where you may not be thinking as clearly as you are? And that exchange. And the idea is that even if you're having suicidal thoughts, if you don't have access to the things that you can use to hurt yourself, you're less likely to act on the suicidal thoughts. It just creates a little bit of distance for the person. And when we have that part of the discussion in the safety planning session, we often focus it on the methods that the person has shared, that they have contemplated already. But as a general rule, we also always ask about firearm access, whether or not that's even been part of the conversation at all. At that point in the session, because firearms are lethal and they are a big part of our culture in the United States. And so a close colleague of mine, Dr. Greg Brown, at the University of Pennsylvania, who co-developed the safety planning intervention, he has a really nice way of asking about firearms. So he says, do you have access to firearms for protection or for sports? So it kind of kind of signals to the person you're talking with it if you're taking a nonjudgmental stance around the firearms and it opens up and opens up the door for a conversation about access. And so the most important thing to do is, again, to put distance between a person at risk and access to a firearm in a moment of crisis. And that can take multiple forms. So it could be removal of the firearm from the home. And there are some states where you can actually release a firearm to your local police department to hold it for a period of time. Some people don't feel comfortable doing that. So there are other alternatives, such as responsible use of gun safes for storage where the person who's at risk is does not have access to the key or the combination for the lock. And these are not mutually exclusive. But you can also dismantle the firearm. So and you could dismantle the firearm and put it in the gun safe if you want to be extra careful. And you can also separate the ammunition from the firearm. And there are separate ammunition lock boxes that can be purchased, which could also be used to separate the ammunition and again, work very closely to ensure that the person who's at risk does not have access to the ammunition in that lockbox. So thank you for mentioning all of those very specific things that that people can do with their firearm, with their with their gun. Can you speak a little bit more about two things, People who really don't want to give up their gun, even if they know it, may be the right thing there? They fear that for a variety of reasons. And can you talk a little bit more about gun locks? Absolutely. So I think it is a really important point to emphasize that some people are not going to feel comfortable passing off their gun to somebody else. And so thinking through other ways to secure the gun is really important. And a gun lock is an important way that that can be achieved as well. People can request them from their medical providers, people who are veterans who are engaged in care in the VA hospital system can request them from the VA. And there are also other programs check out, go online, look to see what's available in your local community where gun locks can be made available. I know here in Rhode Island there's an initiative that's focused largely on child safety, where gun locks are being distributed for free in that context. But anyone can request one, and they don't have to explain why they're asking for one. So I would consider that as an important part of securing the firearm as well. That's very helpful. Thank you so you said something that is like really important that you'd like to highlight and emphasize here is that talking about suicide doesn't increase the risk of suicide. But you also said that that is important to talk about it in the right way. And I'm wondering for someone that is listening to us at this moment, and could it be a parent, a friend, a teacher, a colleague, someone that is concern with people that they live in seems to be suicidal? How a judge advised them to start the conversation. What would be the best way to start that? I think that's such a great question. I think I would just start from that place of care and concern to say, Hey, can we find a place where we can talk privately? I would like to talk with you and share with you my concerns, things that I'm seeing, things that are concerning to me, and I want to make sure you're okay and and start from that place of care and concern. And again, ask opening open ended questions to allow the person to know that you're there and you're listening and you're caring for them. And then again, create the space to listen and I think that is often the best way to start the conversation. Great. Thank you so much, Dr. WINESTOCK. It's our pleasure to have you here. So now a take home message to bear in mind. So it's very difficult even for professionals like psychologists or psychiatry, to know for sure if someone is going to attempt suicide. But there are things we can do as a community to identify and help people who may be at risk. As we've just heard this includes educating ourselves and others as we are doing here. We can learn about the signs of suicide and how to support people under risk and make sure they have limited access to things that they could use to hurt themselves. By working together and offering support. We can help people who are struggling to find hope to get through tough times. So if you or someone is having suicidal thoughts, please contact the Suicide and crisis lifeline. Call or text 988 or access 988 Lifeline dot org. The Lifeline is a 24 hour toll free phone line for people in suicidal crisis or emotionally overwhelmed. You can also go to the nearest emergency room and ask for help. Thank you for listening to our podcast. For more information and related contact, please check out our YouTube channel. Bear in mind the Brain and Psychiatry podcast. Thank you.