An extraordinary perspective on Suicide Risk Assessments from Dr. Tyler Black via Psychiatry Boot Camp

"People are 14 times more likely to die during a hospital stay than outside of hospital for inpatient psychiatry."  In the last episode, I shared an episode of Psychiatry Boot Camp, which is a podcast created by Dr. Mark Mullen to help medical students and junior residents hone their psychiatric skills.  Mark interviews some of the most competent and amazing psychiatrists our country has to offer.  I am excited that Mark let me share his interview with Dr. Tyler Black, who talks about evaluating suicidal patients.  I have never heard any advice about suicide assessments as insightful and compassionate as what Tyler Black has to offer.

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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com.  All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else.  We reserve the right to be wrong.  Nothing in this podcast should be treated as individual medical advice.

Transcript

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SPEAKER_01 0:00

Is there anything that we know for a fact works in preventing suicide?

SPEAKER_03 0:04

First statistically, it's really hard to provide any evidence that hospitalization helps patients. People are 14 times more likely to die during a hospital stay than outside of hospital for inpatient psychiatry. Now, obviously, the reasons people are admitted make a really hard part of the statistics. It's a bias called confounding bias.

SPEAKER_00 0:32

Welcome to Psidactic. Today is Thursday, January 30th, 2025, and I'm your host, Dr. Ryan O'Leary, a psychiatrist and a fellow in child and adolescent psychiatry in the U.S. National Capital Region. This is a podcast about psychiatry and neuroscience. And I created it as a way to help me learn more about the things that I love. In the last episode, I shared an episode of Psychiatry Bootcamp, which is a podcast created by Dr. Mark Mullen to help medical students and junior residents hone their psychiatric skills. Mark interviews some of the most competent and amazing psychiatrists. I'm excited that Mark let me share his interview with Dr. Tyler Black, who talks about evaluating suicidal patients. I have never heard any advice about suicide assessments as insightful and compassionate as what Dr. Tyler Black has to offer. I will not waste any more of your time. Here is Dr. Mark Mullen with Dr. Tyler Black.

SPEAKER_01 1:44

Hey boot camp listeners. Today's episode comes with a content warning, so make sure that you're in a good place physically and emotionally to listen to this episode. I would recommend not listening around small children. And if you are having any difficulty with these feelings, be sure to reach out to your support system. And if you need to, you can always call the National Suicide Prevention Lifeline at 988. Alright, enjoy the show.

SPEAKER_02 2:19

Welcome back to the Psychedra Bootcamp Podcast. I'm Dr. Mark Mullen. Okay, I'm not gonna lie.

SPEAKER_01 2:24

At the risk of sounding like a hot dog, suicide risk assessment is my jam. I want to do consults, I think I'm gonna do forensics, I love having these conversations, and I also love documenting them. And I knew Dr. Black was gonna be stellar, which is why I asked him to be our expert. But holy Toledo. I learned so much talking to Dr. Black, and it has absolutely, immediately changed the way that I approach suicide risk assessments, both in terms of how I move through them, but also how I treatment plan and organize the information in my brain. So buckle up. If you're listening to this podcast, I don't need to tell you how foundational suicide risk assessments are. You'll be doing a suicide risk assessment on literally every single patient you see, and in many cases, you will be required to formally document it using a screening tool, as it's a requirement for healthcare facilities in the United States to receive funding. You will be assessing suicide risk without even thinking about assessing suicide risk in some cases. It just kind of becomes second nature. And to that point, this is a longer episode, but you won't regret listening the whole way through. We're going to cut a little bit deeper than some of the other lectures you may have listened to on this topic, beyond risk and protective factors, although we will cover those in detail, and into the very humanity of what types of things cause people to consider suicide. We'll also discuss how difficult it is for us personally and professionally to interface with such emotionally fraught material. And I hope you'll find that particularly meaningful and fruitful. So today's faculty is Dr. Tyler Black, and Dr. Black, I'll ask you to introduce yourself to our audience.

SPEAKER_03 4:02

But one of the main things that I do in my academic work is teaching about suicide risk assessment, suicidology, non-suicidal self-harm, those types of things.

SPEAKER_01 4:10

And uh Dr. Black, you have quite the presence on Twitter. That's actually where I first ran into you. I read a thread of yours on teaching suicide risk assessment. And I confess that like a year ago, I lifted one of the images and I show it to a lot of medical students. It was so potent that it really stuck in my brain. And so I kind of hope that it's stuck in theirs.

SPEAKER_03 4:28

Yeah, I've I've I've tried to leverage the ability of Twitter to reach a large group of people in order to battle against some psychiatric misinformation, some common myths. So right now we're recording this during the holidays, so I do a lot of posting about the myth about the holidays being a strong time for suicide. Um, in fact, the holidays are are typically when we see suicide rates decrease. So I do a lot of sort of myth busty type stuff, but a lot of suicide risk assessment and suicide statistic things as well.

SPEAKER_01 4:57

Well, I'm very grateful because it's always nice to incorporate some professional development into what is, by all accounts, procrastination. So I really so talking about suicide risk assessment, this is an incredibly common clinical scenario for site residents, regardless of the setting. You know, I I think we see it pretty much every day, outpatient consult, inpatient.

SPEAKER_04 5:17

Yeah.

SPEAKER_01 5:18

Um, when I talk about this, I'm kind of picturing the classic ED consult. I think that's where I've seen it most often, where a patient comes in sometimes on their own, sometimes brought in under police custody, uh, sometimes brought in by a family member who's concerned for them. And so I I think the principles that we discuss will be the same regardless of the setting, but that's kind of how I'm framing our discussion. So when you're doing a suicide risk assessment in the ED, how do you go about structuring the interview?

SPEAKER_03 5:46

So it's you know, so many people when they're dealing with suicide risk assessment, they're gonna get focused and hung up on the thing that happened, you know, the the the incident that brought them to the hospital. But like all psychiatric interviews, you want to start with really good rapport building and you want to be a genuine human being. If you come in to accomplish your checklist and you're reading things off of a paper or you're, you know, like uh, so are you suicidal? So did you hurt yourself? Okay, so then what'd you do? And you're you're not really responding in the conversation, you're not gonna get genuine responses. So usually I spend maybe about five, ten minutes just chatting with a patient. How are you doing? Tell me a bit about yourself. What are the things that you enjoy? Um, this must be really stressful to be here. Is anything you need? You know, just basic human stuff to bring down the defenses a little bit. People after a suicide attempt typically feel better than during the suicide attempt. So they're in terms of the suicide risk portion of it, they typically have less suicide risk going on, but their mind is swimming with what's going to happen next and what's what's sort of coming down the pipeline. So you want to sort of ease them and let them know that you're going to be talking with me and it's going to be a normal human conversation. I always think one of the better ways to do a suicide risk assessment, rather than being very checkboxy, is to just walk the person through their day. Start them off in the morning of the day of the attempt or the morning of the day that they decided to come in. Just say, did you wake up this morning thinking that you'd be here today? That's usually one of my first common questions. Um, just so I get a sense of, was this brewing or was this something that hit you out of the blue? And if they tell me, you know, it was brewing, uh, you know, I think I, you know, I've been thinking about this for a little time. Oh, really, when that starts? And, you know, I use that first question about the 24-hour day. I use that first question as my anchor to see whether or not I'm going to be talking a lot about some historical stuff, or I'm going to be talking about the day in particular. Walk the person through their day and be meticulous about it. So, okay, what'd you do after that? You went up. You in my case, I'm a child lesson psychiatrist. So it's obviously you went to school and you saw your friends and blah, blah, blah, blah. Uh, and then you get to the point where they they start talking about the, you know, the incident that happened or why they got brought in. So I like to walk someone through their day because it also accomplishes a lot of the psychiatric history that you need to gather as well. It gives you a sense of what time, you know, if they tell you they woke up at eight, is that a normal wake-up time for you? Were you particularly tired today? No, not really. Are you often tired today? You actually incorporate it naturally into your psychiatric history gathering. Um, when you get to um, you know, the part where they're talking about sort of what sort of put them into that state, um, whether there was an attempt that was made, a gesture that was made, or some kind of just increased thinking that brought them into the hospital, um, you want to be inquisitive about it. You want to find out more about like the particular details of what happened, but you don't need to know, like everybody will get focused on the exact moment that the decision was made, when in reality, what you're really curious about is what's everything else that led us to that point? And how is it that you're seeing me today? So at a certain point during that conversation, when I'm getting this suicide story, I'm always going to ask them, and how is it that I got brought to see you today? How is it that I'm often I'll be very positive about it? How is it that I'm lucky enough to be talking to you today? Because this is what I love to do, and I'm really glad you're here. How is it how did this happen? And this can start shifting the focus. A lot of people self-present, or they've called 911 after something, or during something they called 911, or they notified a friend, or they, you know, they reached out to someone, and that's why they're in the hospital. And so you can start shifting the focus away from how did you try to quote unquote kill yourself and how did you try to save your own life? Because both things often occurred in the same day. Um and then, you know, you walk them through sort of how they got there. Um, one of the most important structural things is to always ask about how they're feeling now. So we, you know, whatever happened before, here you are now talking to me as psychiatrist. And you know, I'm a doctor, I'm probably here to help you or to save your life, or to, you know, some other idea I have in my head of making your life better. How do you feel talking to me right now? And when you phrase things in this way and you're very open about yourself and very casual about it, and you know, I'll often make a quote unquote joke, but I'll say something, you know, like, if the person's name is is Mark, I'll say, hey, Mark, just to let you know, I'm on Team Mark living here. Like my job is to help you live. But I want you to live a life that's, you know, enjoyable to you. You know, whatever happened, whatever's going on for you, I want you to have a good life, a life that you enjoy, where you achieve everything you want. How do you feel talking to someone like me now? Do you think there's a chance we can do that? And sort of setting the frame of where they're active or or whether the suicidality has peaked and has has recessed. And and, you know, the rest of it is the nuts and bolts of, you know, the risk factors and those types of things and going through a good psychiatric screen. You want to look for major mental illnesses that can influence someone, the presence of drugs, those types of things. Um, you know, in kids, we often, you know, it's really important to ask about trauma. I think it's important in anyone. Um, but at the end of the day, the last part is at some point during your assessment, you have to have an idea in your head. Is this someone that I'm going to be recommending come into hospital or is there someone that I'm going to be sending home? And you want to make that decision. That's why I recommend starting with a 24-hour day, because like an impulsive, serious, I still think I want to die, you know, sort of combo is very likely someone that you're going to want to keep in hospital. A brewing, you know, rescued themselves, I'm feeling a lot better after talking to you type of person is someone that you're likely going to set up for outpatient. So once you start having that formulation in your head of what you're going to do, you can arc the rest of your conversation. Because if you're all if you've already made your decision that I think you have to come in, and depending on your jurisdiction, what the what the rules are for an involuntary versus a voluntary stay, um, don't waste your patient's time. You know, like if they're going to be talking to other people if they're going to be admitted. Um, so, you know, you don't need to be as in-depth if you've made the decision to admit, because they're going to see someone tomorrow, they're going to see someone later today that's going to go through the whole thing with them again. And all you're doing, honestly, is wasting their time. Um, same if you have like an urgent outpatient service. If you've made the decision already that they're going to be an outpatient, um, then they're gonna you're gonna send them to somewhere where they're gonna have to tell their whole story all over again. Everybody reads the notes, but then everybody does their own consult. Um, so so just recognize that in the emergency department, your job is to, you know, assess the emergency. Uh so once you feel like you have enough information, um, then just be a good repairing human being and make sure you send them on their way versus trying to get the full consult in the ER that they're just gonna have to repeat a day or an hour later to their to their annoyance. Yeah, almost every patient will complain about the number of times they have to tell their story. So that's like the general architecture of it. I always think that psychiatry starts with being a good human first. And and so you want to practice talking about suicide. You don't want to come off uncomfortable about it. And if you can frame your questions in a very natural, humanistic way, like like I suggested, you know, walking someone through their 24-hour day, or hey, you're talking to someone who's a little bit life-focused. How does it feel talking to me right now? Um, you'll you'll see genuine responses in in return.

SPEAKER_01 13:34

A great line that I like from a Gabbard book is when in doubt, be human.

SPEAKER_03 13:38

Yes, absolutely.

SPEAKER_01 13:40

And a big pearl that I'm hearing from you is that the primary objective in any initial psychiatric encounter is to build rapport. That is the most important thing for that first encounter. And and when someone is often isolated, making a very serious decision, like considering suicide, the interaction they have with you may be the first meaningful interaction that they've had with an empathic human being in a very long time. And so to some degree, you know, you represent the rest of humanity in that moment. And your ability to build a connection with that person under difficult circumstances really can be life-saving. Um, and hopefully we'll give you some tips on kind of how to do that throughout this episode. Yeah. Another thing that I heard of from you is it's okay to be spontaneous to use language that shows that this is a normal day at work for you, that I actually don't mind being here talking about talking about this with you. Maybe not normalizing ending your life, but normalizing having a conversation about your feelings and the decisions that you're making when you're alone inside your bedroom with somebody. I think that can be really normalizing. But it can be difficult to be spontaneous in psychiatry because the topics that we're dealing with are so charged. And so you don't want to say the wrong thing. And so language is really, really important when having these conversations. And I think this is a really difficult part of language to nail down for even psychiatry residents who do this every day, partially because it has evolved so much, even since I began my medical training in uh 2016. So when you're talking about, you know, suicide, self-harm, suicide attempts, what language do you use with the patient and then academically when you're talking about these things?

SPEAKER_03 15:20

So a few things that you want to try to avoid, language that you just need to retire in your life, is using the phrase um commit suicide, like when did you decide to commit suicide? That that archaically comes from when dying by suicide was either a sin or a crime, right? And and you don't want to head into someone using that type of language because um it's also very closely tied to this idea of real attempts versus fake attempts. And the other thing that you need to just get out of your head is is is the ability to determine what someone's intent was. Were they serious about dying or not serious? I think any language that that and and lots of doctors do this, and I hope not many psychiatrists, but lots of doctors do this, will say something like, Oh, well, you only took 10 Tylenol, it couldn't have been that serious, or something. And you need to remove all of that language from you because of course someone who's holding a bottle of Tylenol might be holding a bottle of 100, but they only take 10. That's still a really serious attempt. You know, it was just a decision away from taking more, and you don't know if their intention was to die in that moment or not because of the outcome. So removing all intention language, you know, trying to determine whether or not they were it was a serious attempt or a real attempt or anything like that is just super important. Um it's okay to be really blunt about, like, you know, I work with young kids. Um, after the age of 10, I can use the word suicide without fear because every child understands the concept and knows suicide, you know, probably by grade three, grade four. These are not foreign concepts to them. But I always think it's helpful to bring up death and dying first. So, you know, have you have you had a lot of thoughts about death and dying? Just so that you will also allow for this version of suicidality that isn't quite I want to kill myself, and more about I want, I wish I was dead and no one would, I wouldn't wake up, or I wish I went to bed and didn't wake up, or I wish I got hit by a car. You know, like a very much more passive version. So if you're thinking about death and dying first, and then you move your questioning into the more specific, and how about self-harm or suicide? Is that something that's come to you? I find that death and dying opens up that door, and often they'll start talking about suicide anyway, uh, but then you can just go directly into suicide. When it comes to self-harm, non-suicidal self-injury, on the conversation side, I think you can use the phrase self-harm, you know, how long has it been that you've been self-harming or and all that? I always think one of the best phrases you can use when assessing non-suicidal self-harm is what does the self-harm do for you? Because almost everyone who does non-suicidal self-injury, like cutting to their wrists or those types of things, their intention is not to die. It's a non-suicidal gesture. And so once you ask, what does that do for you? you're opening up the very real and true possibility that they use that because it helps them. The reason they do it is because it makes them feel better. And of course, we consider it to be, you know, maybe against social norms or something that they shouldn't do. It has some potential for dangers because you've got sharp objects. But really, this is a desperate person using something that works for them. And so that language of what does this do? A couple of other things that I think would be important to remember in terms of language would be try to avoid, like I'm saying this in our conversation, kill yourself type language. It's better to talk about dying by suicide or not dying by suicide. It was your intention to die by suicide or not, because again, kill yourself just has a very direct, it's just going to be a strong language that can really upset people. And it feels like a loaded phrase. So, you know, your word choice does matter, but ultimately when you're having these types of conversations, as long as you keep the red line stuff out, like you don't use judgmental language, you don't talk about committing suicide, you don't talk about whether or not they were serious. Um be yourself. Like use the language that you find works for you. Because the other thing that patients will always do is they'll tell when you're faking it. They'll tell when you're just going through the motions. You have to be yourself to the degree that the person in front of you believes that you legitimately care.

SPEAKER_01 19:21

One scenario that I'm thinking about is, and I have heard this way more than I thought I would have when I started residency, is the patient who takes, you know, maybe it's 400 milligrams of cerequel and says, I just wanted to go to sleep. You know, I I didn't I don't know what I had in mind, but I just didn't want to be dealing with those feelings anymore. How do you I'll I'll show my own ignorance here and say that the language that I have been using is something like parasuicidal behavior. And I like that because it doesn't force me to make a ruling on the patient, the patient's intent. What language do you use for an event like that?

SPEAKER_03 19:57

Um, so when I'm speaking with the person, you know, if they tell me about that, I'm just gonna zero in on the stress that led to that situation because it's the stress that's a dangerous part. The behavior was not dangerous. Taking 400 milligrams of seroquel as a sub-therapeutic dose for schizophrenia is not going to cause significant harm. Um so so I'm gonna move away from the 400 milligrams and the importance of the seroquel and move directly to the stress that brought them there because the same situation a week later or two weeks later could result in a stronger overdose. So that would likely be my move there. When I'm writing, I avoid the phrase parasicide because people misinterpret it. It was intended specifically to be as you used it. It looks like it was suicidal, but it wasn't, but it's now, it's now got a couple of sort of hooks to it. Parasuicide almost always comes up in the context of borderline personality organization. Um, and so there's a almost like it's almost like if someone says someone has pressured speech in the mental status exam, you know what the diagnosis is going to be. This person is definitely gonna be called bipolar. In the same way, if you use the phrase parasuicide, a lot of doctors are gonna instantly tie that to borderline personality organizations or disorders. And then the other, the other thing is they'll instantly think that what you say is that it was designed or designed not to die. Like again, we're getting into the topic of intent. Like it was parasuicidal as in I know that they weren't trying to really kill themselves, or it was parasuicidal as in it wasn't a serious suicide attempt. And so instead of using parasuicidal for most of those types of things, I'll call it non-suicidal self-injury. Or if they if they did it with suicide intent, I call it a suicide gesture. You have to be very careful with the word gesture if you're ever going to use it with a patient, because gesture has a connotation of not being serious. But of course, the actual word gesture, just like our actual world obsession, our actual word for compulsion, they have clinical meanings. And the meaning of a gesture is a behavior that indicates something. And so when someone takes 400 milligrams of telanol, I don't know if they want it to die or not, but I know for For sure that that gesture indicates to me that they're in a lot of distress. And so if I ever use the word gesture to a patient, I'll make sure to qualify what I don't know is whether what I'm not saying by this is that I don't think that you meant it. What I mean is the behavior tells me how much you've been struggling. And then in my note writing, I do the same thing so that the reader of my note doesn't think that when I use the word gesture, I mean the person was faking. It adds me a little bit of writing, but it allows me to use this amazing word gesture, which doesn't know intent. Gesture doesn't know intent. Parasuicidal suggests that it wasn't really suicidal. You know, if you say that the person um, you know, took a non-suicidal attempt, you're absolutely clarifying that you don't think that there was suicidal intent behind. But if you use the word suicidal gesture, you include everything that conveys the communication of suicidality. It could be they wrapped a rope around their neck. You know, um, I commonly work with kids and sometimes they don't hang themselves, they wrap a rope around their neck and then call their parents. Well, what do you call that behavior? Wrapping a rope around your neck is not a suicide attempt. But at the same time, there's no question when you wrap a rope around your neck, you're communicating suicidal distress. And so I like the phrase suicide gesture, but I think you do have to be very careful when you use it. It's kind of like when you're talking about someone's um borderline personality disorder, you need to do a lot of anti-stigma work in your documentation, your communication around it. And then when you're dealing with someone who's using non-suicidal self-injury, first use that phrase and then just NSSI for the rest. Non-suicidal self-injury is any form of self-harm that the person used in an attempt to calm themselves down or something that they go to when they're in distress. The commonest right now is people who do superficial cuts to their wrist or their abdomen or their legs. They're not intending on dying when they do it. We all know that those cuts could never kill you. And you can see the cuts and you can see that they're very carefully organized. They're often very, you know, linear on the arm. Um, if you were a medical student trying to do that to a human being, you'd take your sweet time doing it because it follows the contours of the arm and all those types of things. So you know that it's a controlled, intentional behavior designed to settle someone down. And that's when I'll deploy the word non-suicidal.

SPEAKER_01 24:17

Gotcha. So where possible, suicide attempt, suicide gesture, specifically in documentation, or non-suicidal self-injury, and when speaking with a patient, often self-harm.

SPEAKER_04 24:27

Yeah. Yeah.

SPEAKER_01 24:28

Okay, let's go over some epidemiological factors here. So how common is suicidal behavior?

SPEAKER_03 24:35

So it's more common than people think it is. You know, I work in youth, so I'll start with the youth statistics. About 20% of kids in the adolescent range in any given year will think about suicide seriously. This has been a pretty consistent finding from the CDC going back to 1999. It goes up and down, uh, but um, you know, the range is between 16 and 20%. It's more common in girls than boys, and it's much more common in LGBT, QI2 orientations. So the thinking of suicide is people imagine that it goes sort of thinking about suicide, suicidal behaviors, and then suicide sort of like they're concentric circles. But remember that these aren't concentric circles. There's a lot of people who think about suicide that never do it. There's a lot of people who had never thought about suicide, and then all of a sudden that day they're doing it. So we're not dealing with concentric circles. So 20% of adolescents will think about this. About eight to 10% will report on a survey that they've attempted suicide at some point in the year. So yearly 8% of adolescents say that they've attempted suicide, which is a shockingly high number. You think about a classroom of 30. One of those kids has probably attempted suicide during the year. According to survey, according to records that we can verify, like there was an attempt that resulted in some kind of medical intervention, that usually comes down to about three or four percent. And then dying by suicide um is 0.0056%. So, like you know, if you're a computer that just basically said, you know, this suicidal person in front of me is not going to die by suicide, you'd be right 99.95% of the time for kids. For adults, the math changes just a little bit. Suicidal thinking is much less common. It's about 4% of adults. Suicidal behavior is even less common than that. It's about 2% of adults. And then dying by suicide is 0.014 in the United States percent per year. Um, so it's often expressed, we we express suicide rates per 100,000. For children under the age of 14, it's very rare, probably about one per 100,000 or 1.5 per 100,000. Sometimes recently in the United States, it's been eking up to about 2.5 per 100,000. For adults in the United States, it's about um 14 to 16 per hundred, oh about 14 recently in the United States per 100,000. So the per percentage of people who think about suicide and the percentage of people who die about suicide is extremely weighted towards the thinking about it, not the dying part. And that's always a benefit to you when you're doing suicide risk assessment, because if you have to start with the assumption, this is to help you as a psychiatrist, but also with your goals, this person is very likely going to survive. We know that most people who think about suicide don't die by suicide. Um, so you can come into this, you know, very serious thing that worries so many psychiatrists, you can come into it with optimism, and it's realistic optimism.

SPEAKER_01 27:37

Brilliant. And since, as you mentioned, this is sort of your niche, are there any other common misunderstandings about the epidemiology of suicide that you think are frequently propagated?

SPEAKER_03 27:46

The the commonest ones that I often battle were recordings during the holidays. So there's a suicide myth during the holidays, which I've mentioned. In fact, generally the relationship to suicide and darkness is um it's kind of the reverse of what the myth is. In the United States, suicides are most common in June and July and August when there's far less darkness in this world. Uh and in Australia, it's January, February, and March when they have their least amount of darkness. Our suicide curves are completely inverted in Australia. So we actually think, you know, it's not really the darkness. I I personally believe it's temperature, heat, and activities. Like you're more likely to have long-lasting parties, you're likely to stay up and do things. I think you're more likely to drink during the summertime. There's a lot of, you know, socialized, normalized sort of um substance use during the summer times and things like that. But it it's not actually winter where people are more common. The other one I hear a lot, and this is this is just a nerdy thing for all the psychiatry residents and potential psychiatry students that are listening, would be um whenever you're asked about risk factors, you'll be told there's a, or age, you'll be told there's a bimodal distribution that it's more common in young people and old people. It is a myth that just can't die. You are never less likely to die by suicide than when you're a young person. It increases during your youth years, and then it establishes a high rate by about age 24. The peak of suicide risk before the age of 60 is at 45. It's midlife. And that's precisely where these awful scales, and trust me, when I say awful, I mean awful, like sad persons, will will qualify saying age less than 18 or greater than 60, when in fact the peak of suicide risk is at 45. So even in our own education, we have just really just myths that perpetuate and perpetuate. In the United States, it's a little bit different. In the rest of the world, there is not really a relationship between age and suicide that's very easy to describe. Um, but but we have health care in the rest of the world, and and America really struggles with providing health care. Sorry to say. So we do see men um having really strong rates of suicide at the end of life, and that brings up the overall um sort of end of life picture, such that the average so in this in the States, it is safe to say that older people are more risk for dying by suicide. In the rest of the world, you really have to qualify that by saying men in older age are more likely to die by suicide. In most countries, even in the United States, suicide risks decrease for women as they get older. So you'll commonly, again, you'll see age as a risk factor and suicide is a risk, but really you need to draw an arrow to age and sex because a male is going to have a very different age profile than a female is in terms of suicide risk. And that's commonly mistaught. Um, there's a famous misteaching about schizophrenia that 10% of people who have schizophrenia will die. That's literally used in math textbooks as why doctors suck at math. It's a deteriorating rate. When you first get diagnosed with schizophrenia, you're your strongest risk, and the longer you survive with schizophrenia, the longer the lower your risk gets. And in fact, the rate is half that. We think it's about 4.9% of total lifetime population. Still a high number, but you just can't get rid of that 10%. It's taught everywhere around the world forever and ever. You've probably heard it in your teaching. But it but it is, you know, it's a classic example of you take a 10-year thing and then you extrapolate to the rest of life, but you don't recognize that there's a decay, there's a trend in the years. Um, and that's exactly what the doctors who established that number did. Mathematicians routinely mock it as an awful example of bad math. So you want to get that one just out of your head and divide it by two.

SPEAKER_01 31:40

That is some mind-blowing stuff right there. I am very glad that I asked that question. So thank you for sharing your hard-won expertise. So let's let's move into some reasons that people might consider suicide. And when I thought about this, my brain immediately went to a quote from Kay Jameson who wrote in Unquiet Mind, because I'll never forget reading this and I felt like I got punched in the gut because it it was like a lot of my preconceived notions about the things that people consider when they're thinking about suicide just kind of exploded. And I felt like, oh. So here's the quote I, for example, thought that I had covered every contingency. I could not stand the pain any longer, could not abide the bone weary and tiresome person I had become, and felt that I could not continue to be responsible for the turmoil I was inflicting on my friends and family. In a perverse linking within my mind, I thought that, like the pilot who I had seen kill himself to save the lives of others, I was doing the only fair thing for the people I cared about. It was also the only sensible thing to do for myself. And I think the reason that sticks with me so much is that a lot of times when I'm doing a suicide risk assessment, I will get the answer or even just a uh psychiatric intake, like, oh no, I could never I could never consider suicide because I've seen how selfish it is. I've seen how it destroys a community, destroys a family. And um what she is saying here is that that's exactly it, guys. She feels like she is destroying her family and she's doing it as an act of what she perceives as, to use her words, in a perverse way. She perceives this as a gift to her family to sort of remove herself from the equation. So what are some of the most common reasons that you see that people consider suicide?

SPEAKER_03 33:21

It's it's a great, it's a great question and such a profound way to think about it. Um one of the things that I love to teach, and this is you'll you're not going to find this in a podcast, uh, in any other podcast, you're gonna find this in any other textbook. This is really a a special for you, is um we've lost the we've lost the knowledge of Emile Durkheim. Um it's very rare for psychiatrists to know Emile Durkheim very well, um, a social uh a social philosopher who basically pioneered social work in the late 1900s, but he did some great writing on the motivations of suicide. And I've modified his writings to a degree that allows me to teach it very easily. But I always think if you're really interested in this type of sort of what goes through someone or why would someone think this way, the founding fathers of the things that we do, the founding people, fathers and mothers of the things that we do, uh, they've thought about this and they've processed it. And this comes to some philosophical things. But Durkheim had a great system, and I use it all the time. Uh, I want you to imagine two axes, and this is for motivations for suicide. The first axis is under stress, how do you organize yourself? Because an extreme in either direction is going to be a motivation for dying. And then the other axis is how connected are you to the people around you or your society? And an extreme in other either end is going to become a motivation for suicide. So let's start on one extreme. Uh, let's we'll just imagine that there's four quadrants then of extreme. There's one axis pointing in one direction, one axis pointing the other direction. So on our first axis, we have how do you handle stress? If you if you are disorganized and you fall apart and you can't control yourself and you're impulsive and all those types of things, you have a form of motivation and suicide called anomic suicidal motivation. This is Durkheim's term. This is the chaotic, uncontrolled response to stress. This is what we knock out of the park as psychiatrists when we do things like safety planning, when we talk about ways to calm yourself down, when we do deep breathing exercises, when we talk about calling a friend, when we say reach out to 911. Because for people who are anomic, where they just can't organize themselves, they're out of control and they impulsively think about suicide. It's not something they've been planning, but it just kind of occurs to them, and then that's what they do. All of those interventions that we we knock out of the park and we recommend all the time, they're beautiful, they're amazing. That's exactly what that person needs. So you're pairing the motivation, which is I couldn't organize myself. I had no idea what I was doing. I was overwhelmed, it was too much stress at once, and I just kind of blew up. And you're saying, hey, the next time this happens, here's some things you can do. But if I go to the underend of that dial, I'm going to turn all these things that I've praised that we do, safety plans and deep breathing and calling a friend and these are cruel and inhumane suggestions. So on the other end, Durkheim describes fatalistic suicide, someone who's thought through the possibility, like KIV in in in your quote, someone who's actually considered a lot of things. This might be someone who's suffering from a real major hardship that they can't overcome. For example, let's take someone who has a life-ending disease like ALS, and they know for sure that the ALS is going to kill them, and they've started to lose their dexterity, and they know what's coming next. Start losing my dexterity. Soon I'm going to start becoming uh slower and not able to move, then it's going to be hard for me to ambulate. I'm going to have to be in a wheelchair. Then after I'm in a wheelchair, it's going to be hard for me to breathe. I won't be able to swallow, and then I'm likely going to die at some point. And then you turn around as a psychiatrist and they tell you that they're suicidal, and you say to them, Have you ever thought about listening to some nice music? Have you ever thought about calling a friend? What about deep breathing? Have you ever considered doing like just imagine how inhumane that sounds? You're completely missing the mark. When someone has fatalistic or they've thought it through and they're encountering a real hardship or what they perceive to be a hardship and they've gone through this and they plan this and they they can't figure out anything else. Your job is not to provide coping strategies. Your job is to help them fix their problem or improve the quality of their life. It's much harder work. It's very easy to tell someone to do deep breathing. It's very easy to say call a number. And for people who are nomic, it's really going to help. But for people who are fatalistic, you're basically slapping them in the face. You're insulting their intelligence. Of course they've considered deep breathing. Of course they've tried to talk to a friend. They can't solve their problem. So you have to get into problem-solving mode. You have to get into, you know, here's how we can help the quality of your life. So in the case of ALS, I'm, I can't solve ALS. But if I could, I would instantly relieve that person's suicidality. But if I could improve someone's quality of life, I might, I might reduce the chance that they they want to die. So you have those two axes and they're in complete opposition. And as psychiatrists, we often get very rote in what we recommend when someone's suicidal. So you might be surprised to hear I don't offer these trite sort of deep breathing, you know, call a friend, you know, listen to nice music suggestions. When I detect that the person has significant fatalistic suicide, I become a lot more realistic and you've got a really hard road ahead of you, but here's what I want to do to help.

SPEAKER_01 38:32

This is some really next level stuff that I have not been uh introduced to training.

SPEAKER_03 38:37

Never taught. And it's just so practical. Absolutely. So you have that one axis, and and because they're in opposition, if you can think about the motivation, you can think about what you're gonna offer. Both things can be true. Someone can say fatalistic ideation and motivation and anomic motivation. So they've always been thinking about it, but then something sends them over the edge. If you detect both, use both strategies. I'm gonna solve your problems, and here's some calm down strategies you can use. On the other axis that Durkham describes is your connection to society. On one sort of extreme, we have what Durkham calls egoistic suicide or someone who's completely disconnected from those around them. This becomes a motivation because why does it matter if I'm here? Why does it matter? Nobody cares about me. Um, if I were to disappear off this planet, it wouldn't make a difference. I'm disconnected. And a few groups that you have to be really aware of how egoistic suicide works is first for victims of intentional trauma. Um, really big content warning here. Very sorry for all the listeners, but anyone who's intentionally abused is also intentionally isolated. It comes with it. The motivation to die by isolation, um, egoistic suicide uh comes with intentional suicide. There are literal textbooks on how to groom children for sexual assault, and they all start with isolation. A parent who hits their child, the first thing they tell that kid is, don't tell anyone I did this. If you tell anyone, you'll be in more trouble. You pair isolation with intentional abuse. You have the stress that can cause suicidal ideation, and you have the motivation to die in egoistic sort of nobody cares. The other group that you really need to think about for egoistic motivation is LGBT plus community. Because often when we develop our sexual feelings and our sexual identity, we don't really know, we don't really understand, especially as adolescents, that this is a common experience. We all are very uncomfortable. Even for myself, I'm heterosis. Um, I was very embarrassed about my sexuality as I developed it. When you add also, no one else talks like me or no one else around me thinks like me, and you feel like completely alone in that, um, it's very easy for someone who has a non-normative identity to feel like they don't fit in and it becomes a motivation to die. Of course, there's large LGBT plus communities. Um, you will find your place, but especially when you're developing it, you can feel very egoistic. And it gives them a motivation to die. So when you're when you're approaching egoistic motivation, when someone describes to you that they don't feel like they fit in, no one would care, you have a really easy job. Connect them to people who care. I mean, that's you know, if if they're someone who's struggling with their identity, connect them to an LGDPT positive group. If they're someone who's um, you know, a victim of trauma and they they don't know how to trust anyone ever again and they can't really open themselves up, they need significant trauma work and or to work in victim services groups. Um, if they're all alone during the pandemic and they couldn't have anyone to talk to, um, they need to start, you know, hanging out with some people, whether it's online or in person. They need to start really working on a way to start connecting into others. Maybe it's picking up a hobby that you know you can do with other people, maybe it's joining a group, but your your focus can be dedicated to we need to connect you to people because your motivation is nobody cares. Of course, galactically, I'm I think you know if you follow my on Twitter, I do astrophotography. We really don't matter in the universe. We are nothing. You know, I hate I struggle with this all the time. Our planet is going to be wiped out by heat death, and there's nothing going to be left for all of humanity. Um so so there's a truth to I don't really matter, but we all matter locally. We can influence people around us. We have impacts in our community. You know, I see, you know, I can get very, you know, fatalistic about, you know, there's no point, the world's gonna die of, you know, global warming or whatever it is. But of course, I'm my in my day job, I'm helping people every day. So I can have a local influence. And so we want to build that person's local connections. And then on the other extreme, Durkheim, he called this altruistic suicide. I've modified it to the words um socioistic. I'm a burden to other people. I'm weighing down other people, they'd be so much better without me gone. You're valuing them over your own life. It's a heroic move in case, you know, she's seeing it as a heroic move in her writing. But in reality, we all know that survivors of people who die by suicide are not grateful for the opportunity to experience the suicide. It's a very painful thing for them. It's like a nuclear weapon. You can even be tangentially related to someone who died by suicide and it it thrusts you back for days or weeks or months. This idea that pops in is my relationships are more important than my life. And if that ever comes up, you're probably dealing with socioistic motivations, and your job is to disconnect that a little bit. So the the groups that I think about the most, um, anytime someone does something for a cause, so the Tibetan monk who sets himself aflame to protest China, um, that person is using socialistic motivation. They're saying, My cause is more important than my life. Um, very unrealistic to think that you could dissuade that person from dying from suicide because they really believe in their cause if they're doing that. The murder suicide that, you know, obviously is quite spontaneous, but usually is preceded by domestic violence, almost always committed by men, though they're Are some female murder suicides almost always committed by men? Those are definitely sociistically motivated. The whole goal is to hurt the other person and then just escape the consequences of that hurt. So socialistic motivation, typically you really want to disconnect that that you know that that connection to those other people. The thing that I see a lot is the intense relationships that are very unstable. So it could be a parent-child relationship that involves a lot of fighting or an overconnected romantic relationship that's hot and cold with lots of breakups and lots of challenges. And again, their life hinges on how their relationship is going. Like it really is all about the relationship. When, you know, we see this all the time when that off and on relationship, when it's in the fighting moments, it's all about, I just don't want to be here anymore. Of course, even as a psychiatrist, you'll help that person. Maybe you'll admit them to hospital, maybe you'll pick them up as a patient. And then a week later they've made up and everything's fine. And you realize that the relationship is determining whether or not they're suicidal. Um, and then you do have a goal of helping them examine is this a healthy relationship? Is there a way to disconnect a little bit? I'm often working with kids on saying, maybe you're you and your mom are just fighting too much. Maybe there's a neutral place you can live for the next little while just to bring the heat off. Because of course, when a parent and child are fighting all the time, and we know that children are more impulsive, those fights could be really dangerous if suicidality is on the map. So the the kid could think something like, I'll never, I'll never make my mom happy, so I might as well die. Or this will show her, I'll really do it and really hurt her. You know, that's a totally socialistic motivation. And we need to remove that by disconnecting the child from the mom. We need to, okay, why don't you stay with your dad for a while, or why don't you stay with grandma for a while, or why don't we talk about ways to leave the house when you're really upset, or maybe I need to talk to the mom about you need to stop fighting about bedtimes because this is just not worth it. And disconnecting that social connection. So you can see how motivation in this question that you've asked, it unlocks a secret that almost nobody teaches in psychiatry, which is if you can truly understand that architecture, whether it's fatalistic or anomic, whether it's egoistic or socialistic, you can target your treatments. You can target what you're going to do about it. Um, so none of these things are um exclusive. You can have all four, uh, but it tells you what you need to do. And of course, the last motivation is no motivation. We don't get to know what's in someone's heart. But I know that there's lots of people who will intentionally do a suicide-appearing behavior for a goal that is non-suicidal, to get something they want, whether it's to tell a person, I really need you in my life, don't leave me. If you leave me, I'll die. The intention is not to die, the intention is to get that person back. Um, the person who takes 10 Tylenol and then calls 911, it'd be hard for me to construct that their overall mission was to die, but they're clearly in distress and they're reaching out for help. So sometimes there isn't really a motivation to die. There's more just a, I'm in a lot of distress over my situation. Um, so you have to recognize that no motivation, their intention is not to die is on the map. It's a hard thing to talk about publicly. And I always worry about this, even when I'm speaking on a podcast directed at psychiatrists or psychiatric trainees. We have to acknowledge reality that some people fictitiously do things. Some people are not honest about their intentions. Um, nobody wants to talk about this. Everybody wants to say, believe your patient and believe everyone. But there are people who lie. There are people who you know use really intense emotional words in order to manipulate other people and those types of things. And you always want to be looking out for secondary gains in suicide um gestures, especially if when they're repeated a number of times. What is this person getting out of this? And trying to see if there's a way to reduce that. So sometimes when a person presents for a suicide gesture, they're surrounded by um caregivers and it's a big deal and you know the the the injury is very low. And if this is a repeat thing, you still want to be human, you still want to show them a lot of support and love, but maybe don't make it as big a show because maybe it's the show that their brain is seeking. Maybe it's the whole 9-1-1 experience that their brain is seeking. When it's a family member who keeps rushing to the person's side, you need to really teach that family member how to be a little bit more nonchalant about their care. Oh, okay, this has happened. Let's take you to the hospital rather than, my goodness, what did you do? You know, because they might be actually getting um a reward internally or even unconsciously from that frantic behavior. So it's a tough part of motivation to discuss. Um, I think it's realistic. Um, if patients, if if former patients, if um people with lived experience hear this, they might not like that we're talking about this, but it's just a nature of reality. Um and we do have to confront it as psychiatrists, otherwise, we get very cynical about these things. We have to be honest in how we approach it.

SPEAKER_01 49:02

It's the nature of reality, and of course it's not just our patients who do things that are not always direct to get the outcome that they want. You know, that is a normal part of being a human being.

SPEAKER_03 49:11

Absolutely.

SPEAKER_01 49:11

You act you act in a way to get the result that you want.

SPEAKER_03 49:14

People often tell me that a child I'm working with is very manipulative. I'm like, in my head, I'm always like, every child is manipulative.

SPEAKER_01 49:20

Every child does everything they can to get what they want. Exactly. It reminds me of the attention-seeking behavior. Okay, so is there something wrong with wanting attention seeking? Exactly. Exactly. And of course the answer is no. Um, so let me just briefly summarize here the Dr. Black exclusive on Durkheim suicidality. So we have the, and what I really like about this is it reminds me of my favorite answer to any multiple choice question in medical school, which is treat the underlying cause. Yes. If that's an option, you pick it, right? And what you're talking about is looking at suicidality in the same way. So what is the reason that the person is feeling suicidal? Is it this anomic, this understressed, sort of disorganized, chaotic? And if that's the case, then we can respond by planning a safety plan, being pretty concrete about the things we can do to avoid this negative outcome. Is it fatalistic? It's premeditated, it's rigid, it's the person with the terminal disease who has thought their way through it, and there's no creative restructuring that you're going to be able to do in that moment. And so you get into their shoes and you solve the problem with them. And by the way, if the problem is not solvable, at the very least, you are reminding them that they are connected to the human community and that somebody cares about them. Yeah. And then we have the egoistic, the sort of isolated. Um, you mentioned this could be someone who's the victim of intentional abuse. And in that case, what we're trying to do is kind of reach out and bring them back into the fold of their fellow human beings and remind them that there are people who they can have connections with. Yeah. Um, and that those connections are important and they can give them a sense of meaning, a sense of belonging, which are both protective factors against suicide. And then the final quadrant is the socioistic quadrant. Um, use the word some people think sort of heroically when they're doing this. And in this case, we can kind of remind them that they are seeing themselves as a forest with some greater cause, but in fact, they are a tree, you know. And what is unique about them being a tree? And why is it that we do not need to focus on the forest? And we can sort of bring them back down to a different way of thinking about their role in the world. Yeah.

SPEAKER_03 51:24

Yeah, that's I love that. That's great.

SPEAKER_01 51:26

Okay, so Dr. Black, let's get more concrete into after I'm a psychiatrist resident and I get called for a suicide risk assessment. Um, you know, what is my job really? So sometimes it can feel like we're being asked to predict the future and make a recommendation. Is that what we're being asked to do?

SPEAKER_03 51:41

Certainly what you're being asked to do. It's impossible. Uh so one of the things that, you know, I I work almost entirely in an emergency department. I do um probably about five to seven hundred suicide risk assessments a year. In my career, I've done probably over 10,000. Um so um uh I love my job. Like, imagine that. You know, my whole job is predicting suicide, my whole job is assessing suicide. This is most psychiatrists' most scary part of the job is what do I do about suicidality? And yet I love my job and I do it all the time. Um, because there's two things that allow me to do this. The first is I don't try to do impossible things. People will ask me, is this person high risk, low risk? I don't know. There's no way to know. Um there's there's really good research, and I encourage people to develop their own knowledge on this, but the idea of stratifying people into high and low risk buckets for suicide has a lot of problems. Every system does it, but it has a lot of problems. About 50% of people who die by suicide would be scored on a suicide risk assessment tool as having low risk for suicide. And we know that 99% of people scored as high risk for suicide won't die by suicide. So there becomes this really interesting statistical problem, and hopefully this doesn't get too wonky. It'll give all the former medical students um a heart attack, but the positive predictive value. You have your sensitivity and specificity when people think they all understand specificity and sensitivity for the value of a predictor. So the specificity is um what's the what's the chance of this being a false positive? And the sensitivity is what's the chance of this being a false negative? You know, something that has no false negatives is highly sensitive because it always picks up positives. Um, something that is highly specific is is you can really trust the negative because it it never picks up false negatives. But positive predictive value is the thing that comes in here. Remember, I was telling you the base rate of suicide for humans is like 0.00% 0.01% for adults and 0.005% for kids. Um, so it doesn't really matter if the sensitivity is 76% or 80%, because if the sensitive is 80%, that means that there's 20% false positives. And if the true positive is 0.0015% and the false positive rate is 20%, then you have about 4,000 false positives for every true positive. It's a useless test. The positive predictive value of what we do is less than 1% in terms of suicide risk prediction. Um, you know, machine learning with every EMR part of every human being that we come in contact with, like these massive computers, they can maybe get a positive predictive value of 2 or 3% in seven days and probably about 2% in 30 days. There's no chance our weak human brains are ever going to be able to predict suicide like that, unless we have some new understanding or some new test that that just has an amazing sensitivity and specificity. So you can take the idea of my goal is to stratify this person into high risk and low risk and just toss it out the window. Just relieve yourself of it. Always say, I don't know. Whenever asked, what's the chance? What's the risk? Now, a system might force you to indicate high risk or low risk in certain scenarios. And how much of a disruptor can you be? Well, you still have to follow your laws and regulations. In the United States, it still is a requirement, I believe, of whatever your hospital accrediting organization is, is are patients determined to be high risk and is there special moves for them? But I'll tell you right now, the science is very clear. When we do that, we harm people who we identify as low and we harm people who we identify as high. Because people who are identified as high often have their rights taken away from them. They often have things done to them against their will or they're hospitalized, even though there's a very low likelihood that they're going to die by suicide. Um and we overfocus on them and we take, we do a lot of harmful things, potentially medications they don't need and those types of things. And then on the low-risk group, we wait list them and we send them home and we don't offer them services and we tell them your problems aren't that bad. And these are people that have, you know, 50% of people who die by suicide are technically low risk by our assessments. So this, the, the actual nature of stratification is harmful. So for me as a humble clinician who can't change all the systems that I work in, I just relieve myself of the responsibility. My job is not to predict whether that person that person is going to live or die. And the good news is medical legally, no one expects that to be your job. It's only other jerky doctors who are giving you the consult or the desperate parent who is just really wanting to know what's going to happen with their kid. It's it's never the legal system. The legal system is quite clear that we can't predict suicide. The second part is there's something you can actually do that's really helpful and fun, which is assess for risk and protective factors. What are the things in their life that make it more likely that they're gonna die by suicide? And what are the things in their life that make it less likely? And is there anything that I could do that would add a protective factor? Is there anything that I could do that would relieve a risk factor? Everybody wants to operate on the high risk, treat high risk condition sort of rubric, like does this broken leg need a cast or surgery type of rubric? But really what you want to look at is every human being I encounter, what are their risk factors that I can improve? And what are their protective factors that I can improve? And if that's your goal of suicide risk assessment, you'll love your job. It's an easy job and it's helpful. If a patient tells you, I'm having stress at my job, and then you say, hey, I'll write a letter to your boss or let's see what we can do about your job, you're improving their suicide risk. Their relative risk is improving, and you have no idea about their absolute risk. You know for sure, though, that if you're relieving a stressor on them, you're improving their suicide risk. So you can work entirely in the realm of relative risk adjustments without ever knowing what the final score is. I never get to know if the person's gonna live or die, but I always know that I can improve or deteriorate the risk of suicide.

SPEAKER_01 57:49

And in this model, what we had talked about earlier, you know, the sort of ultimate decision that you often have to come up to is does this person require acute inpatient psychiatry? And by your mental model, what you're saying is if you're recommending that, what you're saying is there is a modifiable risk factor that we are going to be able to change by admitting the person to inpatient psychiatry.

SPEAKER_03 58:10

Exactly. And, you know, um, a lot of times it's like the behavior dictates the outcome, like a serious suicide attempt with 400 tablets of Tylenol dictates that the person must be admitted to psychiatry. But in reality, if you don't have a proposed treatment for them in hospital, what are you hospitalizing them for? If by the time you see them in the ICU, they're like, well, that was stupid, I shouldn't have done that, you can hop into your anomic mode and you can start doing some safety planning and you can discharge them. Um as long as they have a system of support around them, it's it's routine for me to be discharging children from the ICU after serious overdoses. It doesn't have to be that everything that you determine to be a high-risk behavior results in admission to hospital. And there is a bit of a brainless sort of, I think this person really tried to die therefore I'll admit them to hospital. You always want to think of your treatments as a doctor as what will benefit them? What am I proposing to do? And are the benefits worse the risks? I will rhetorically ask, and there's a right answer here, um, are there any risks to being hospitalized? Um, of course there are. Patients are routinely assaulted on psychiatric units. They're scary places to be. You're isolated from people, you can't do the things you normally do. Your rights are taken away from you. Um, you see all sorts of things you don't want to see. Now, psychiatry, I love it, but we get a lot of stuff that society doesn't want to deal with. Um, an acute inpatient ward on a psychiatric unit, you can see some pretty horrendous things that society just does not want to see. And if you're bringing someone in with no reason, just because they've done something and you don't have a treatment plan, you're exposing them potentially to significant harm without any possibility of benefit. That's being a bad doctor. Like we're supposed to do those things when they're worth it. If I really think we need to get started on a medication right away, I need to observe them every day. I'm treating something that needs daily uh treatment. Maybe it's even, I need to dedicate like one or two days to solving some of these problems in your life, and you being inpatient will really help me do that. Um, it's of course it's worth it. But make sure that it's worth it before you do it. And so when you do this risk assessment thing and you're actually looking at protective and risk factors, if you identify a modifiable risk factor that hospitalization is a strong helper for, then yes, consider hospitalization. But if all you detect are non-modifiable risk factors or chronic risk factors that hospitalization has no chance of helping, and I'll give a great example. If you feel if you feel like the person has a long-standing chronic suicidality that has had multiple admissions, and you're proposing admission number 18, what are you saying, really? Um, I'll give you another couple days. You have to start thinking about what's my long-term goals here. And sometimes the best decision you can make is not to admit that patient and to finally start, okay, we need to do things in their community because clearly that's where the issue is.

SPEAKER_01 1:01:11

And of course, that's one of the foundational concepts of dialectical behavioral therapy, you know, which was sort of one of the premier marquee evidence-based manualized therapies for highly suicidal people. You know, it was how can we manage this in the outpatient setting, not to simply cover our own, I can say this in the podcast, cover our own asses medical legally. You know, it's um how do we help this person to build a life worth living in the long term? And sometimes that requires not reinforcing maladaptive behaviors.

SPEAKER_03 1:01:38

And and, you know, DBT, I have some challenges to its evidence. Like I'm not as I'm not as overwhelmed by its evidence, but I will say DBT is a container. When people are in DBT, it has a it when you're in distress, you call your DBT therapist. Like it's a full container. And this is probably what makes DBT superior to other psychotherapies, is, you know, the general psychotherapist will say, Yeah, call me eight to five or, you know, you see me once a week or something like that. DBT really is an intense container. And and probably one of the reasons that it's so well matched, and we think about it a lot in people who struggle with chronic suicidality, is because it can actually contain the emergencies. Whereas other psychotherapies basically say, if you're in an emergency, call call your hospital.

SPEAKER_01 1:02:20

So I think this is really the meat and potatoes of what our listeners have tuned in for. So let's go ahead and dig into some of these risk and protective factors.

SPEAKER_03 1:02:26

Sure. So I like to think about risk factors in sort of chronic and acute. When I say chronic, what I mean is these are long-standing, lifelong things that are unlikely to change, not necessarily unmodifiable, but difficult to modify. So we have age and we have sex, and we've talked about that, that really age and sex are quite related. And age is not a simple statement. It starts at adolescence, it increases, the risk increases to age uh 45 or so. Um, it decreases again to 60, and then for men it increases, and then for women it decreases. So it's a complicated statement to talk about age. Um, but uh like all chronic risk factors, you can disregard the age. You can disregard the demographics. Like if I'm talking to a 60-year-old suicidal person or I'm talking to a 12-year-old suicidal person, I don't tell the 12-year-old, well, I'm not gonna worry about you because you're in the wrong demographic. I mean, everybody who we talk to, we have to seriously consider for suicide risk. So a lot of these chronic risk factors, they're important to know for the baseline, but they're not gonna really influence what you do. Um, so previous history of suicidal ideation, previous attempts, um, uh, any sort of health problem, and and we often zero in on mental health problems like depression, anxiety, those types of things. But any health problem, cancers are related to suicide, and diabetes is related to suicide, and heart disease is related to suicide, strokes are related to suicide. Anything that causes long-term suffering has a relationship to suicide. There are a number of uh diagnoses that are higher risk than others, like eating disorders, depressions, probably higher than, for example, anxiety, which has a relatively low risk increase. But we do want to think about all of the diagnoses that are influencing them. Having um uh cultural beliefs uh or coming from a culture in which suicide is a little bit more sanctioned. So there still are societies in where suicide is an expected gesture to do uh with certain failures. There are a lot of religions that prohibit suicide, and so that can put a pressure on someone, but that can also be suicide protective. And chronic risk factors, you could just go down the list, um, but they're typically things that you know about. They set the baseline, they don't typically become the targets. There's one thing that I used to describe as a chronic risk factor, and I want to make sure that all future psychiatrists never use this language, and that's using race um as a risk factor. Uh so indigenous people are more likely to die by suicide, and and colonially, we have interpreted that as I mean, indigenous people are more um are sort of like a higher risk group. Nope. Racism is the high risk problem. Systemic discrimination and systemic barriers are the high risk problem. They are overrepresented in suicides. LGBTQ community is overrepresented in suicide. There's nothing natural inside them that makes them more likely to die. It's how they fit in their society and how society treats them that that does that to them. So whenever you're using an underrepresented or minoritized group, try to think a little bit less about them being higher risk and think a lot more about them being overrepresented because it lets you narrow in on the actual risk factor that's affecting them. The indigenous person is not suicidal because they're indigenous. If the indigenous person has systemic pressures on them, that will increase their risk for being suicidal. It's the systemic pressures on them. It's the fact that they can't connect with their culture, it's the fact that literally their land was stolen from them and intergenerationally they've lost so much. So if you know you it's very easy to individualize it and say the indigenous person is more at risk for suicide, and that language is really problematic. Problematic and I've really worked to remove it. Unfortunately, you know, for a lot of my training, we're trained in colonial systems. We we don't get that education. It really means something to do that.

SPEAKER_01 1:06:10

Aaron Ross Powell And sometimes our education follows what is easily testable on multiple choice questions. And something like a group that is overrepresented, statistically speaking, is easy to test. And something like how to dismantle colonialism is not necessarily so easily into a multiple choice question.

SPEAKER_03 1:06:26

So so um, you know, if the if the multiple choice question asks you like which group is more at risk for suicide, you know, that's probably not the time to stomp your foot down and get the question wrong. But um, you know, they're they're gonna, you know, definitely indigenous and then white and then non-white populations in the United States. That would be the order of suicide risk. But um, but it's overrepresentation. We just know it's across indigenous cultures across the world. Uh in Canada, um, we have uh an area of Canada to the north on the east side called Nunavut, and their rate of suicide is between 80 and 100,000, 100 per 100,000 per year, which is about eight times the Canadian rate of suicide. So um, you know, but it's all the barriers uh that that people encounter when they when they are indigenous. So I always think that a lot of the textbooks will have these static factors like age and sex and race and blah, blah, blah. Um, but they don't they don't adequately explain that you need to hold that in your head and then kind of disregard it for your treatment because we don't have treatments for age, we don't have treatments for sex. There's nothing I can do about someone's lack of previous history of suicidality. Like if you use that as the basis of your decision making, you're gonna trap yourself. If I admit someone on the basis of they've attempted 15 times before, what am I gonna do about that? Now it's 16, you know, I can't change that. So so they're important to know. They help you set a baseline, but they're non-modifiable generally. And, you know, obviously in this case of systemic factors, we we want to modify them, but they're hard to modify in in the individual setting. So then you draw this dividing line, and then you start talking about acute or modifiable risk factors. And these are things that you really want to think about classically. What first you want to think about the attempt, or if there was a gesture, if there was something that was happening. Was it serious? Could it have killed them? Are they still actively suicidal? And very important for learners to know the difference between active and passive suicidal ideation. Active ideation is I want to jump off the bridge at 3.30 today. Passive ideation is boy, it would be really nice to be dead. Passive ideation, much lower risk than active ideation in terms of immediacy. And obviously the right answer if someone says they're going to leave immediately and go to the bridge and die is their attempt to go to the bridge. So, you know, the acuity of it is very modifiable. Uh, then in terms of personal risk factors, you want to think about things that you can change. So an untreated or an undertreated or a treatment that isn't working for someone for their illness, you can modify that. If they have access to weapons, you can remove weapons. If they have substance problems, you can address their substance problems. If they're intoxicated, they need to sleep it off and then get the supports they need. If they don't have the social supports they need, you need to add those. If they're in a life crisis, you need to work them through their crisis and develop a strategy for it. If medications aren't working, you need to switch their medications or find a new scheme that works for them or remove medications. Remember that deprescribing is an important psychiatric ability. And then whenever you're thinking about dynamic risk factors, you're thinking about things uh non-static, these are acute, modifiable, um access to healthcare, anything you can think of that you can modify, you put into this risk. What I like to do in my head when I'm documenting is do a here's the chronic, here's the chronic risks that I see, the non-modifiable life risks that I see, risk factors that I see, and here's the acute and modifiable, recent changed, you know, risk factors that I see. And then do the same with protective factors. Chronic protective factors would be generally optimistic, someone who works really hard, someone's achieved really good things. Wealth is actually correlated with less suicide. That's another myth that that suicide is a wealthy person's problem. Um, suicide and wealth go hand in hand, but um impoverished people are more likely to die by suicide. And so there are a number of protective factors that can be chronic and then acute. You know, when you're talking to them, if they feel like much better, like I'm I'm feeling really positive, I'm glad I survived, um, I have good friends around me, um, I have a great therapist that I can talk to and they're helping me through these things. These are all things that can be protective factors. And if they're missing, you can add them.

SPEAKER_01 1:10:36

When we're going through our suicide risk assessment, when we're documenting it, when we're thinking about what is the plan going to be and how can I justify it? I think that zeroing in, especially on those dynamic risk factors is what I'm hearing. Yeah. Am I able to remove access to lethal means? Maybe that will require inpatient psychiatry. Maybe it won't. Does this patient have undertreated symptoms of depression, under treated symptoms of psychosis? Yeah. Are they experiencing mania or hypomania? Those are things that we can modify with inpatient hospitalization, um, connecting them to healthcare. I think one of the big ones that you mentioned, and I want to make sure it gets a lot of attention, is substance intoxication and withdrawal. This is one where if you have a patient who has any level of suicidality and they are, especially on a stimulant like cocaine, methamphetamine, or alcohol, something that sort of turns off that frontal lobe in that case. This is a patient that really needs to achieve sobriety, I think, before you discharge them into the world, it would be very difficult to justify.

SPEAKER_03 1:11:32

And you have to be very nervous with stimulants because, of course, after the stimulant high comes the stimulant crash. And you know, if if there's a suicidal behavior on stimulants, you can imagine how awful they're going to feel when the when they're going through withdrawal from that. So being really aware of the toxicromes of intoxication and the need for supporting people through sobriety, it's it's really easy to say, oh, you're drunk, go home. Um, but you know, when pe some people, when they've stopped drinking, that's when they actually feel the worst. And, you know, addictions are a vicious cycle with mental health. And often people use substances to escape their mental health problems, and often the substances cause mental health problems. And so you have to be really sensitive around those times.

unknown 1:12:14

Dr.

SPEAKER_01 1:12:15

Black, do you want to go into the four C's that you had mentioned?

SPEAKER_03 1:12:18

So here's the thing. For a long time, I had this uncredited, but this came from the Journal of Australasian Psychiatry in 2002. I'm forever indebted to the authors who wrote it, but it's the four C's of suicide risk assessment. This is kind of just an approach you can take as you're doing your assessment. Remember, I said be human, walk someone through their day, all this type of stuff. Um, that's gonna come to one of the four C's. So the four C's are collateral, common sense, confidence, and changeability. Um, I'm gonna do that again in right order. The four C's are collateral, confidence, common sense, and changeability. And the importance of the four C's is not like a rigid thing you have to do, but if you're always thinking in this terms, you're gonna get suicide risk assessment right. So the first is collateral. Psychiatry typically does better the more collateral history we have. Um, because a person brings their personal biases into the interview and they all tell you things and you you'll have no idea what's their perspective and what's like a little bit more of an objective reality. So, for example, if a patient tells you, um, I've never succeeded at anything in a depressed state, that's how they really feel. I'm not doubting their genuineness. But if you talk to their family member and they go, This guy, he's got all wards. This guy is incredible. You know, it it you know, an objective outside view can really tell you a lot about the person that you're working with. When someone's in a state, of course, that state is going to color what they're presenting. So in suicide risk assessment, I can't overstate the importance of collateral gathering. You can do it confidentiality. Um, most states have laws. Um, in Canada, we're protected by this as well. When you're dealing with an emergency situation, you're allowed to do things that help in the emergency. So this is what allows people to intubate unconscious people and those types of things. Um, in the same way, I don't have to break confidentiality. I'll tell the patient, hey, I'd like to call someone you know. Is there anyone you think? I'm not gonna tell them anything. I just want to ask them questions about you. Are you okay with that? And then when you talk to the person, you say, Look, I'm here in the hospital with them. I needed to ask you some questions about them. Even if they asked you, hey, what's going on? Say, I can't share that with you, but your information is going to be really helpful for me. And then just collect information. What are they like? How do they do under pressure? What do you think is going on in their life? Is there anything going on that I don't know about that maybe you you think is going important for them? Um, what are your worries about them? What are your what are their strengths? What are their weaknesses? Those types of things. And when you add collateral to your history gathering, it does the second sea it improves your confidence. And when you're doing a suicide risk assessment, confidence becomes an extremely important factor. And confidence isn't, am I confident that I can predict whether or not they live or die? Confidence is do I feel like I got the genuine information that'll help me do a suicide risk assessment. So if I go down and I see a 16-year-old boy and I say, hi, my name's Tyler Black, I'm a schiatrist, I'm here to see you, and they go, hey man, fuck you, and they spit at me. I'm gonna have a lot of work to do to get an accurate suicide risk assessment. I can just already tell what's gonna happen. Are you feeling suicidal? No, get the fuck out of my face. Like that's like it sucks. Like I feel bad they're in that position, but obviously I can't do a suicide risk assessment if they're not giving me genuine information. If my rapport is really poor, if they're very being very dismissive, if I'm talking to someone and it's clear that they're just trying to say the right answers, how are you feeling today? I'm fine. Oh, what happened? Oh, nothing. Are you are you feeling suicidal? Nope, I'm fine. It's like, that's too quick. We're not having a real discussion here. I can tell that this is not genuine. Then your confidence is undermined and your ability to even determine what are true risk factors and protective factors is really undermined. Collateral helps you with that, but also just really working on that rapport. Remember, I set the stage. Work on rapport first. Break down that barrier so that they feel like they're talking to a human. Because if you can get rapport in your suicide risk assessment, your confidence will be high. There's such a difference. And, you know, you're in in the middle of your residency training, but you've had these interviews where you've talked to someone and you can tell that you've connected. They're telling you, oh, thank you so much. It's really made a difference to me. Or this is this is the first time I've ever really talked about this stuff, but it feels really good to share it. And you're having real human moments. You actually you're in that moment, your confidence that you've connected with them is very high. But you've also had the experience where you just know they're just giving me answers. Uh, this is not real.

SPEAKER_01 1:16:49

And this is one of the most, I think, uncomfortable, I would call it a dialectic that we have to deal with because we want to respect patient autonomy. We want to believe patients, we want to always be on the same side as our patients and certainly have that unconditional positive regard. But the other side of that spectrum is who's the patient that I'm most worried about in terms of what they're telling me in the moment? The patient that says, oh, this was nothing serious, I'm better now. I'd like to go home when the collateral is telling me something differently, and the facts surrounding the event are quite different. And as a resident, that's a to for me, it's a really difficult emotional experience to have where it's like, I want to believe this person, and yet um kind of everything in my gut is telling me that you don't have to be a doctor to know that the magic words are I'm no longer suicidal.

SPEAKER_03 1:17:37

Exactly. Um there's this weird tension that we have to explicitly address, which is the right answer if you really want to die is I'm fine. And the right answer if you really want to go into hospital and not die is I'm not fine. Um, we've set that up. We've made the ticket to hospitalization be suicidality. So we're totally to blame for that. But um we have to confront that reality that the truly suicidal person has no motivation to tell you about their suicidal uh behaviors because you can only thwart them. And the person who has nothing but non-suicidal but bring me into hospital motivation has every reason in the world to tell you that they're suicidal. So um we have to confront that. And again, this is kind of comes to this theme that I often talk about within the profession. I still I try to talk about outside the profession, but it, you know, there's not a lot of sympathy for psychiatrists in this regard. But we do deal with things that the rest of society has said, hey, it's your job. Um, so for example, I don't like the feeling. I've never liked the feeling when I've I've used involuntary mechanisms on a patient, but I know for sure that the laws are very clear that I must. I know very sure that the expectations on me are that I must, that my professional college tells me that I must, that my training tells me that I must, and that the family members of the person around that person definitely demand that I do these things. And so um uh I love patient autonomy. It's one of the you know one of the things I always fall back to. But if I'm talking to someone and I know that we haven't talked about the real thing, and I'm really professionally worried about their suicide risk, there's a lot of risk factors that aren't addressed. There's no protective factors in place, and they just did something serious, and I'm really worried about the next 24 hours, even knowing that I can't predict it, there's only one answer, and that's be a professional. My job is to be a professional. Professionally, I believe you need hospitalization. I need to use hospitalization right now because I'm not getting to the real you. I have so many unaddressed concerns, and we need to sort this out before I can let you go home. That's what the law tells me that I must do, and that's what my conscience tells me that I must do. And I find that my conversations with patients go much better when I display my humanity in that way. I will explain my dilemma to my patients. I care a lot about you, and I'm hearing that you're saying you're feeling better, but here's the situation I'm in. This attempt that happened was really serious, it nearly killed you. When we've talked, I've identified a number of risk factors that really worry me, or I just don't feel like I'm getting the complete story yet. I don't understand yet what's happened and why we're here. And it would be, I would look like the world's worst doctor if I sent you home right now. Like it would be in the newspapers, you know, patients sent home despite being suicidal and despite having, you know, all these risk factors. I I'd just be an awful doctor. I can't do that. And when I put myself out there as a human who's also struggling with this, you know what I often get from my patients is, yeah, I get it. I understand. But if I have that same conversation, is I'm taking away your rights, you know, this is a serious attempt, I'm gonna hostilize you, and I don't display my humanity, I get the pushback. Why are you doing this to me? You know, like this is awful. And obviously it's not gonna change my decision, but it just feels much worse. Um, I'm still gonna have to do the professional thing. So earlier when I started this conversation, I said, be genuine. Even be genuine in your risk assessment, even be genuine in your treatment planning, even be genuine in your involuntary hospitalization. There are very few psychiatrists in this world that enjoy using involuntary mechanisms. Display that. Be human about it. I hate doing this. I can't wait until I'm able to remove this involuntary part because I really want to work with you. You know, whatever it is, demonstrate to the person that you're a human being.

SPEAKER_01 1:21:19

It's such an emotional experience. You know, you really have skin in the game as a resident, as an attending. And to me, what this sounds like the opposite of personally is medical school. Uh specifically the preclinical years of medical school, where you're just told put your head in a textbook and you don't get to see a patient for a while. Yeah. To our listeners, you know, this is coming down the pike, but I want you to hear, aside from how emotional it can be and how much skin you have in the game, one of the first things Dr. Black said, which is, I love this work. Yeah, you know, and I feel the same way because it really is a calling and it really is meaningful, and it really does give you a reason to get out of bed in the morning and go to work. And so for me, you know, that was one of the reasons I think residency is so much better than medical school, is I really have a sense of meaning and purpose in my work. And the outside of that coin is sometimes you are stuck in a really difficult human situation. And um, I guess your advice is kind of go ahead and put your cards on the table and don't shy away from the fact that we are a human too.

SPEAKER_03 1:22:13

More importantly, when you're documenting your suicide risk, if it's an easy decision, feel free to write it very trivially. If it's a hard decision, it better be a few paragraphs on why you've done what you've done. Like there's no there is no medical legal standard that you made the right call. The medical legal standard is was your reasoning sound? And if you don't put your reasoning on paper, it didn't happen. So the commonest thing I'll see is deny suicidal ideation, therefore I sent them home. I just explained the paradox. Every truly suicidal person will deny suicidal ideation. So it can't be that simple. It's deny suicidal ideation, plus my risk assessment of them indicates that they have few risk factors that I could modify and lots of protective factors that are protecting them. I feel okay and saying like you can't just hinge it on what they said. You can't make it look simple. One of the commonest myths I have about documentation is if you write down suicidal thinking, you're kind of forcing your hand that you must then certify the person or you must then involuntarily hold them or whatever it is because you've kind of documented negative risk factors. But that's not true. You can document a whole bunch of negative risk factors. If I took a patient who had 35 previous attempts and came in with another serious attempt, and this is admission number 20, 36 to the hospital, um, they have a ton of chronic factors, they have the system in place, they are seeing the therapist they need, they have the diagnosis they need, they're just keeping on coming back. I'm gonna write all of that out and then say, I'm in a really tough position here because I'm really worried about this person dying, and yet I know that there is nothing I can do in hospital that will change this outcome. We have the treatment in place that they need, they have the um the diagnosis that works for their situation, the treatment they get is is what they and really the person in charge of them living and dying is them, and I don't get to control that. And I'm gonna write that down on my risk assessment, and I'm putting it right there on paper that I think this person could die, and I'm really worried about that, but I can't change it. This is no different than the oncologist documenting a stage for, you know, N1, M1 cancer. I'm really worried this cancer is gonna kill them, but I'm not gonna give them chemotherapy and radiotherapy because it's not gonna change that outcome. There's no difference between the two. But psychiatrists often treat it like there is a big difference. There isn't a difference. If you see everything's being addressed and you're still worried and you don't have any treatment mechanisms to offer, it's okay to say there's nothing more I can do for this person. I'm worried about them, but I can't see a role of hospitalization here. I just don't see what it accomplished. It have 35 previous attempts, their stays have ranged between two days and 10 weeks, and none of this has modified their behavior. I can't just propose a week in hospital just because. Like it's just not possible. So you can write those things out. And guess what, medically legally protects you? That paragraph medical legally protects you. Writing, I'm not worried about their suicide risks, so I'm sending them home. That's gonna kill you medical legally if anything happens. So even if you cynically just think about medical-legal medicine, it's the right thing to do to just write down your human thoughts about the experience.

SPEAKER_01 1:25:35

And one thing that's coming across clearly, because this drives me absolutely off a wall, is you're saying I am making this determination. You're not saying this notewriter believes it is you making the decision, you're the expert, you are the one on the line, you're having the emotional experience. Take ownership of it and really write your thoughts because frankly, that's your job. Yep. Any other phrases you'd recommend we definitely do or don't include in terms of the documentation, or would you just say document your clinical decision-making process?

SPEAKER_03 1:26:04

We all know that borderline personality disorders in organizations have a tight tie to suicidality and suicide behaviors and even suicide deaths. I think at this point of the game, if you're not being a good advocate when you're using the diagnosis of borderline personality disorder, you're harming your patients. Um, there's such a stigma to that disorder. There's a lot of fight, should we change the language or whatever? I don't think that's ever going to help until we change the stigma behind it. But this idea of borderline personality disorder is false. Like 80% of people who have borderline personality disorder in five years have clinically significant improvements such that they no longer meet criteria for borderline personality. It's probably not even really a personality disorder. There's some people that it does stay quite a while for and they have long ongoing suffering for. But this idea, this stigma that these people are always going to present with non-suicidal gestures, or they're always gonna act like they're suicidal, or this myth out there that most people with borderline personality disorder die by accident from suicide. They didn't really mean to do it. This is all that stigma that just hangs around the disorder. So if you're ever describing the diagnosis or giving the diagnosis, a don't give the diagnosis from an emergency department, only talk about personality organizations. Um, but say you know the person and you're documenting it, um, do do some advocacy there. Borderline personality disorder is treatable. It's one of the only personality disorders that we have good treatments for. Most psychotherapies are good treatments, um, have efficacy. The effect sizes aren't high, but they're treatable as opposed to some of our other personality disorders, which we have no efficacy for. The the course of borderline personality disorder is not as chronic as the phrase personality disorder suggests. It starts in adolescence and it persists through adulthood. But really, when we do longitudinal assessments, whether it's five or ten years, a great majority of people will have. Significant improvements in their symptoms during that time. And the the crisis that they're presenting with, it's very common for someone who has the borderline label to be treated as if their crisis doesn't matter, that the problem is in with them. But of course, someone who's structurally unable to tolerate abandonment, who just got dumped, it's a big crisis to them. You need to help them. You need to, so, so uh I do think that when you're documenting anything about borderline personality disorder, as psychiatrists, we have roles to be advocates. And I think there's a 1999 version of borderline personality disorder that's still very prevalent in the medical community. And there's a 2022 what you're getting in residency about borderline personality disorder version of it that most physicians don't know about. And I think it's our job to advocate in that way when we do that in suicide risk assessments. A magic phrase, and this is really something that will help you both medical-legally as well as discharging patients that you're worried about, is I've constructed a plan that I think works for now. But if they are ever in trouble, here's what they can do. Create your plans with an opt-out clause. If you're struggling, come back to the ER, whatever it is. I do think that we have a tendency, and nursing staff do this a lot. A lot of doctors who aren't trained in psychiatry do this a lot. They try to get patients to contract for their safety. Promise me you won't die. There is no evidence that works. People who die of suicide have cell phone contracts, they have rent agreements, they are gonna get married in a year. They have so many promises that they've made that they don't honor when they die by suicide. The idea that they're gonna promise their way out of this is ludicrous. It puts too much pressure on you and it puts too much pressure on the patient, and it's fake. We know for sure it doesn't work. Suicide contracts have never stood any amount of evidence. But if you can get person to rent courage, hey, here's the plan that we've developed. Do you think this could work for you? Do you want to give this a try? I think this might work for you. And they say yes. That's a different proposition than promise me you'll never harm. Because then you can throw in, if this plan doesn't work, if all of our efforts here they don't seem like they're working, come back to the ER. I'd love to see you again. Right? And you can put that in your notes too. But if you use the phrase they didn't contract for safety or they, you know, what you're basically saying is I gave them an impossible task that they failed, and that's why I'm hospitalizing them or not hospitalized or whatever it is. So when you're when you're thinking about uh your treatment plan, think about it as renting their courage as opposed to getting them to promise that they're never gonna die by suicide. Because if they feel like the plan's gonna work for them and you feel like the plan's gonna work for them, just have a contingency for if it doesn't work. It's okay to not be confident that it's gonna work. It's okay to not be 100% sure that your treatment plan is gonna work. And I always remind psychiatrists, welcome to medicine. What's the chance the chemotherapy is gonna work for a cancer? It ain't 100%, but we still offer it. We do treatment plans on the balance of probabilities. If the patient feels confident the plan might work and you feel confident that the plan might work, give it a try. Just give it an opt-out clause. So instead of using language around contracting for safety or promising safety, use language around this plan we developed, the patient felt like it could work for them, and I feel like it's an appropriate treatment plan. And if it doesn't work, I've instructed them to come back to the emergency department.

SPEAKER_01 1:31:30

And in the end, you may not be a hundred percent confident in your determination. And in fact, if you are, I would argue you're probably missing something. Probably missing something. So what you're doing is you're putting down your thought process, you're documenting the Russian protective factors, talking about what you're going to modify. Yeah. Okay. Dr. Black, I know this is a very controversial topic right now, actually, especially on Twitter. I feel like I see this mostly on Twitter. Um, inpatient psychiatric hospitalization, I think the evidence is a little bit mixed. I'm not sure there's any really rock solid evidence that inpatient hospitalization can prevent suicide. So I guess my question for you is does it? And is there anything that we know for a fact works in preventing suicide?

SPEAKER_03 1:32:09

It goes back to our original conversation. Um, first statistically, it's really hard to provide any evidence that hospitalization helps patients. People are 14 times more likely to die during a hospital stay than outside of hospital for inpatient psychiatry. Um, obviously, the reasons people are admitted make a really hard part of the statistics. It's a bias called confounding bias. The reason that people are admitted are usually things that are risk factors for suicide. So it's very hard for us to ever truly disentangle the admission to hospital for the reasons that they're being admitted to hospital. The only way we'd really be able to know is take a random group of people and randomize them to hospitalization or not or see what happens to their suicide risk, right? But we can't ethically do that. So so it's hard, but but the the reverse to that is we often talk about hospitalization as if we're confident that it will help them. And it's very hard for us if we really look in the mirror and really address our problems and say, you know, that psychiatric inpatient unit, it's a healing place. Um, I've worked on many inpatient psychiatry units, and I know that the staff try really hard and they're constructed the best they can, but they can be really scary places and they can be really traumatic places, and they're really hard places to be. So it always comes back down to that. We know for sure that there are harms related to hospitalization, isolation, scary, seeing things you don't want to see, trauma, um, being held against your will, losing your rights. Um, the payoff should be worth it. So if you're ever in that dilemma, just make sure that your treatment plan is solid and that the hospitalization is a necessary component of your treatment plan. And if it's not necessary, avoid it. There are more than enough severely mentally ill people who need hospitalization for legitimate treatment reasons. You don't need to be hospitalizing people that don't need to be there. Um, so so if you ever have an alternative to hospitalization, it's to me it's like having an alternative to surgery that could work. It's almost always a better idea to offer, hey, let's try the non-surgical alternative first before we go to surgery because the surgery is higher risk. On the other hand, again, probably podcast or your podcast listeners are the best audience for this. This doesn't wear well in public, but there's just reality that some people need involuntary treatment. Um there's no I don't know a way around it. There's been models proposed. There's an Italian model called the Trieste model where there's no involuntary stays and stuff like that, but they have robust in the community supports for their severely mentally ill people. In the society we live in, in the structure that we have, some people, their mental illness is such that they need involuntary hospitalization.

SPEAKER_01 1:34:55

Well, and most people in the general public, and maybe even people who are in the psychological space on social media, do not have significant experience treating people who have untreated primary psychotic disorders, who are in the throes of maintenance.

SPEAKER_03 1:35:07

It's one of those weird things where you never want to really say this, but you do want to say this is have you ever really talked to someone who's been floridly manic or floridly psychotic? Like it's so obviously a brain problem that they are not in control of. It's so obviously dangerous and impulsive and anything could happen. It smacks you in the face. I I don't think there's anything more jarring than talking to a floridly psychotic or floridly manic person. Um, but of course, most people when they think about mental illness, they think about, you know, office-based stuff, like I'm sadder than I should be, or I'm having suicidal thoughts, whatever it is. But when true, you know, florid illness presents, it's really robust. It's hard to deny.

SPEAKER_01 1:35:51

And on that note, just anecdotally speaking, you know, if I've involuntarily hospitalized, I don't know, let's say 50 people, I think 48 of them a few days later, when things have calmed down, when we've had a family meeting, when we have treated some of these undertreated psychiatric symptoms, they are saying, wow, I feel so much better now. Exactly. And I think in the grander math, 48 hours of involuntary hospitalization, at least in my assessment, is well worth it when you consider that you could be saving a life and keeping this person on the planet for many decades.

SPEAKER_03 1:36:22

Yeah, and and we have to hold space and acknowledge that a lot of our patients are mistreated. Psychiatry has a long history of paternalism, long history of mistreatment of people. Um, there's an over reliance on medication in many psychiatric circles. A lot of the things that people who have lived experience who've experienced harm say are true, and we have to hold space for that. But they also have to hold space in their advocacy for the knowledge that for many people they benefit from hospitalization. And for many people, there's no alternative to hospitalization. And um, and that's where I think a lot of the Twitter sort of war sort of is in a stalemate because people who have lived experience of harm, um, especially the very sort of anti-psychiatric side of it where they're very against it, it's a form of anti-psychiatry that I have a lot of empathy for because when you've experienced harm, it's okay. It's okay to be really angry at the people that harmed you. But um uh there's an unwillingness to open up to other patient experiences. It's like my experience is the only experience. Psychiatry only harm. Psychiatry is only awful. And yet we know in working with our patients long term and even listening to patients. You know, I'm on Twitter all the time with people who tell me how much medication has helped them or how much hospital has helped them, or the psychiatrist has helped them. So the unwillingness to hold all of the patient experiences is one of the flaws of the anti-psychiatric view. Um, we have to acknowledge that some patients are harmed by what we do, but we also have to acknowledge that some patients need what we do. And our goal is to get that balance right. We want to bring as many people in that we can help, and we never want to bring people in that will harm. And that's the, you know, that's one of the big challenges of psychiatry.

SPEAKER_01 1:38:01

Final question for you, Dr. Black. This is a really difficult emotional topic for trainees to deal with. You know, I think about my first year of psychiatry residency, uh, mostly inpatient, mostly people who are, like you said, either floridly psychotic uh or actively suicidal, quite suicidal. I would need one to two hours every day after work to sort of regain my feet, to unwind, to do something to deal with just the heavy weight that this is, because it is a big decision and sometimes it does feel like it's falling on your shoulders. Do you have any advice for trainees who are dealing with this topic? And sometimes for the first time.

SPEAKER_03 1:38:36

I do. The first is if you're a trainee in psychiatry, I'd really strongly consider it's part of your training to do psychodynamic work. I'd strongly consider can doing psychodynamic therapy too. It's not for everybody, um, but I think trainees that don't avail themselves of going through the therapeutic process um might not resolve some of their own hangups that will be become biases or challenges as they approach situations clinically. This is a podcast, but I can see that you are younger than me. Um I have confronted my own death. Uh, you know, and and it is normal when you're going through training to see death as like an absolute thing that we have to avoid. But I have bad news for all the trainees. Everybody dies. Our goal as physicians is not to prevent death. Our goal of physicians is to prevent suffering. That's what we do. Um we we we have no ability to prevent death yet. Death is 100%, it never fails. And um other professions, for whatever reason, I I never get this. Psychiatry is almost the worst at handling the prospect of death. If you ever want to see a bunch of psychiatrists in a tizzy, tell the psychiatrists that they think that the person's gonna die. Uh these people who are supposed to be the masters of mental health and the most amazingly insightful physicians that we have, they fall apart when it comes to death. Yet oncologists, cardiologists all the time face death in the face. And so I'd say to trainees, remember your training. Um The oncologist who has nothing to offer a patient who's dying of cancer doesn't flee the situation or unnecessarily try to treat them in a heroic but futile attempt. They sit with the patient, they offer things that'll improve the quality of their life, they feel sad about it, they might get sad with their patient, they might get sad after the patient leaves, they take moments for themselves, whatever it is. Physicians deal with death. Psychiatrists, I have news for you, you have to deal with death too. Because when you become death avoidant, you do dumb things. You do things like hospitalizing people who treatment will never benefit, or being one of those people that anytime someone mentions the magic S word, you send them to the emergency department. That is death avoidant bullshit. It doesn't help anybody. You have to confront the reality that everybody dies. You have to confront another tough reality, is there's only one person who has to decide whether that person lives or dies, and that's the person you're treating. You have no ability to stop them. People die inpatient on suicide watch with no personal effects. I I have awful videos that I watch as a suicidologist of how people die in prison situations. And people are very creative. It doesn't take a lot. Um so the idea that you can even stop someone from dying is something that you have to let go of. You have to confront these issues, and fortunately, great thinkers have gone there before you. Brush up on your philosophies of life, brush up on your psychoanalytic views of things, brush up on your the your email dichrams and um you know, some great like your your Kant and your Camus and your like there's philosophical discussions about life and death that can really affect psychiatrists. And if you're someone who hasn't confronted that you can't prevent suicide, you really can't do it. You are not able to do it. And you can't stop someone from dying. If you haven't confronted that internally, these things will wreck you all the time. The the other thing that I'd like to get out there is about 80% of psychiatrists will have a patient that they've closely worked with die of suicide. It I've had I I work in emergency psychiatry. I have I've had three personally. Um and I work with kids. I really struggle. It is hard when someone you care about dies of suicide. Um the prospect of them dying of suicide is scary. You really have to make sure that you've developed a good support system around you because the work that we do in psychiatry, like I said, is the work that the rest of society has decided too hard to think about. I have personally cried coming home from my career, probably about 20 or 30 times. I've worked for 14 years. I've come home sometimes, I've heard about a child abusing an animal, and I've hugged and cried my cat all night. Um I've had a patient die, and I've been a wreck, and cried, and cried to my wife, and called my brother, and um be vulnerable. Be it's okay to be vulnerable. You can't be a hero in these situations. We see the worst of the worst. Um, so so really get ready for that part of psychiatry. It is a tremendous honor. It is a job that I love. But like a paramedic or a mortician or a all these people who do these amazing jobs that help society, they just deal with things that the rest of people don't understand. No, I I I think I have it rough for the traumas that I've seen working in an emergency department. I can't imagine what it's like to be a paramedic arriving to a scene on a DOA. Like the the literal gore, the violence that you must see must be incredible, or arriving to domestic dispute in progress. So these jobs that are highly stressful, that are doing things that society has kind of shunted to them, the reason society's shunted it is because it's too much. It's too much to bear. So when you're doing stuff that's too much to bear, make sure that you have a good support system around you. Uh for any listeners, um, I I make myself very available. I'm available on Twitter. You can reach out to me at Tanner Black32. I'm on email at dr dot titterblack at gmail.com. Um even if it's just I'm struggling with something, reach out to someone, and I can be that person. You know, I offer this to all trainees, and now that I'm on this podcast, all of your trainees are my trainees. Um, so you're not alone in this. It's a hard, hard job. Psychiatry is taxing many other specialties. Their whole bread and butter is seeing as many patients as possible. I don't know what your limit is in a day, but I I don't think I could see more than 10 patients in a day. I don't think I could do it. I don't think I could do it. If I did it, I'd probably fall apart. Um, it's a hard, hard job that we do is to develop your support systems.

SPEAKER_01 1:44:52

Thank you so much for being vulnerable with us. So important to model that for trainees. And I think those are just amazing words of wisdom that you shared with us. And thank you so much for sharing your expertise on this podcast. I am so excited about this. It's gonna be awesome. Um our trainees are gonna listen to this and march into the ED the next day with full confidence, and then they're gonna regurgitate this to all of their third-year medical students. I hope they do.

SPEAKER_03 1:45:17

That's the that's the goal, and and hopefully push upward a little bit. I will say the newest generation of trainees has me very optimistic of a new form of medicine that's very patient-centered, anti-colonial. Um, you know, we have to be aware that there is an older brand of medicine that still exists in this world that is a lot more tightly regulated and hierarchical and sometimes a little bit less patient-focused. So push push downward and upward. There's lots of things that you can write in your consults that will benefit seniors, that'll benefit well-established attendings, and um, and use your impression section for advocacy. That's, you know, um, that's what it's there for. People are gonna read, they're gonna see your note. It's five pages long, they're gonna skim everything, they're gonna read impression, diagnosis, and treatment plan. Throw some advocacy in your impression and help change the medical field.

SPEAKER_01 1:46:06

Hopefully, we've stimulated many listeners to do the same. Thank you so, so much for your time. Thanks so much.

SPEAKER_02 1:46:18

Thanks for listening to this episode of Psychiatry Bootcamp. Special thanks to the Behavioral Health Education Center of Nebraska for their support. If you have any questions or feedback from me, you can email me at Psychiatry Bootcamp Podcast at gmail.com or reach out to me on Twitter. Of course, this podcast is not intended to be used in medical advice or in any legal proceedings whatsoever, including to establish a standard of care. This podcast is intended only as a supplement to a complete accredited psychiatry residency and is grossly inadequate to rely on for medical decision making. It is intended to entertain and inform you should always rely on your own clinical judgment when making medical decisions. And contact your physician for medical advice.