Suicide Risk Assessments: Using Predictive Models in a Personalized Way

Preston: [00:00:00] I wish we could prescribe friends. 

Margaret: Maybe the real antidepressant was the friendship we made 

Preston: along the way. No, but yeah, like, go pick up your friend at, at the pharmacy and they're gonna genuinely be invested in your life and hang out with you and do things like, is that something we could prescribe?

It'd be such a protective risk factor. 

[music]: Patient. 

Preston: And welcome back to How To Be Patient, the podcast that airs every Monday with two really fun and cool residents. 

Margaret: Two, two sec. Well, when this comes out, I'll not be a resident, so amend, amend yourself. You, you'll be referring to me with one really cool, fun resident, and 

Preston: also Margaret, 

Margaret: I'll be in fellowship when this comes out.

Preston: So today we're talking about the the how and um, the who of, um, suicidal behavior and suicidal ideations. I know last time we kind of went into the why people die by suicide, but knowing why something happens doesn't help you predict it. [00:01:00] And that's ultimately what we have to do a lot of times as a psychiatrist is predict why people do things.

And that's why our icebreaker for today is gonna be a little prediction game. 

Margaret: Okay. 

Preston: So Margaret, what is the weather right now in Boston? 

Margaret: Raining? It's raining. 

Preston: It's raining right now. It's been raining for 15 

Margaret: weekends in a row in Boston. 

Preston: I want you to try to predict what the weather will be in one week in Boston.

Raining exactly right now. It would be raining right now. Um, yeah. How sure are you? 

Margaret: I checked the 10 day forecast, but I don't remember if I remember. Yeah. Okay, 

Preston: so you check the 10 day forecast. So, but I don't know if that's right, if you had 

to put a number on it, how sure are you? 

Margaret: Um, 50%. 

Preston: 50% 

sure that it's probably gonna rain exactly one week from now.

Okay. 

Margaret: Yeah. 

Preston: Now I want you to predict the weather in Boston six months from now, 

Margaret: snow. Cold. 

Preston: [00:02:00] Exactly what, what it is right now. 25 degrees, 

Margaret: there may be an inch inches snow on the ground, maybe 

Preston: 25 degrees, maybe an inch of snow. Mm-hmm. Gotcha. What about eight months 

from now? 

Margaret: 37 degrees and rainy. 

Preston: Okay. How sure are you that 

Margaret: 40, 30%, 

Preston: 30% you, you'd 

bet on it.

Margaret: I'm not a, I'm not a gambling woman. 

Preston: Okay. What, what about 20 years from now? At this very moment? I have no idea. That's what gonna be a Boston idea. Like, 

Margaret: we'll see what the globe is doing. 

Preston: Mm-hmm. You want me to give you a, a guess? Yeah, a guess 

Margaret: 20 exact years from now, like summertime. 

Preston: Mm-hmm. 

Margaret: Um, I'm gonna guess it's gonna be humid and sunny on today, 20 years from now.

Preston: Okay. And, and how sure are you of that 

Margaret: 20%? 10%? 

Preston: Yeah. 

Would, would you put anything meaningful down on that guess? My reputation is a 

Margaret: podcast. 

Preston: Yeah. 

Margaret: No, I [00:03:00] wouldn't. 

Preston: So I, I think that the point of that is, um, even though we have all these pieces of evidence that can guide what our predictions might be, and there are reasonable guesses, right?

You, you check the 10 day forecast, it gives you a lot of information about what it's gonna be in like in a week. And we know Boston goes through cyclical seasons, so we can predict reasonably that it might be snowing, but we don't know that for sure. You know, if it's just gonna exactly an inch of snow on the ground or a certain temperature.

And the same goes for even like a few decades from now with, with the way climate change is going. And the, the point is that it's really hard to make these predictions with chaotic symptoms systems, sorry, slip and the weather is a classic example of a chaotic system. 

Margaret: Yeah. Or like a system we don't totally understand also.

Preston: Yeah. So that's my follow up question, which is what to, what is chaos to you? 

Margaret: Doing this podcast with you? Um, 

Preston: true. 

Margaret: What is chaos to me 

Preston: in the, in the context of like [00:04:00] probability, what is a chaotic reaction? I 

Margaret: think it's like I cannot predict what's gonna happen. There's no pattern. There's many different things that are impacting it that I can't either know about or don't know about.

And if I know about it, I can't really calculate what they're going to do next. 

[music]: Yeah. For 

Margaret: example, they might try and do a pelvic floor exercise during the middle of an episode, you know? Mm-hmm. In theory. 

Preston: But the, the, and the interesting thing about a chaotic system, which, which first of all you said it perfectly, I think, is that you have some system that is nearly unpredictable, but each of its like small factors is made up of non-random interactions, but when combined into a system becomes so complex that you can't tell which it's gonna go.

So a great example of this could be like a coin flip, you could argue is like a chaotic reaction where it appears random to us. There's a 50% chance of it landing on heads or tails. But if you could perfectly recreate every [00:05:00] scenario where like the amount of pressure I apply on my thumb, where the quarter's sitting on my thumb and I flip it in the exact same temperature, pressure, weather conditions, it will land in the same position every time.

Mm-hmm. 

Mm-hmm. Because none of those interactions are random in themselves, but because it's a chaotic system 

Right. 

We, it produces seemingly random, uh, outcomes. 

Right. Right. 

So. What's interesting about weathers is something that we call, like a type one chaotic system. 

Margaret: Wait, where did these types come from?

You gonna tell 

Preston: me? So I, I'm stealing this from, from the book Sapiens. Okay. I dunno if, if you've ever read that. I haven't seen much about it elsewhere, but I thought it was a really interesting model mm-hmm. That the author used. So type one chaotic system is, is something that's really challenging to predict since everything like we we'd say with like a HA hurricane or weather.

But then there's a type two chaotic system and the difference is a type two chaotic system. One of the factors that makes this challenging to predict is that when you probe it or kind of inquire about its [00:06:00] prediction, it also changes the outcome. 

Margaret: Oh. So it's like trod, dingers. Chaotic system a little bit.

Yes, it's true. Yeah. 

Preston: Or the observer effect. So the economy is like a perfect example of a type two chaotic system where PE inflation, if you're trying to predict inflation by asking people about their concerns for inflation and raising fears about inflation, you're actually going to affect the outcome of what you're seeking.

Mm-hmm. Well, and what is the economy? But a bunch of different combined human behaviors and decisions, 

Margaret: which are also chaos 

Preston: tied to chaotic systems. 

Margaret: Yeah. That's chaos. Going into chaos. 

Preston: Right. And, and then that comes to our job as psychiatrists, which is how do you look at a population of humans with infinite interactions, chaotic factors, and then immeasurable, non-random interactions and try to predict people's behavior and try to guess from the population who is going to attempt suicide, who's going to complete suicide.

Margaret: As you mentioned, the one where it's [00:07:00] like it changes it by observing it. Um. Do you think of that in psychiatry as like, I could see an argument that it, like when we ask about it, it can impact it, whether that's towards the outcome we want or towards the outcome we don't want, as like a type two system.

Mm-hmm. Does. 

Preston: Exactly. Yeah. And so we, by investigating, we are absolutely probing it. I think there was a time in the past where we thought that merely bringing up suicide or asking about it was pushing it towards the outcome we were avoiding. And I think we know that not to be as true now. 

Margaret: Yeah. Although there are people saying that in the, in the public media.

And I'm currently reading the book, bad Therapy, um, against My Will, and the first chapter is her talking about children being screened for depression and their suicide questions. So just, just to say you're right, the field, um, doesn't think that suggestion alone causes it, but there definitely are modern naysayers.

Preston: [00:08:00] Yeah. It's just like the, the skepticism is like, what if you ask someone if they're suicidal? They're like, I never thought of that. 

Margaret: Yeah. Basically, literally. It's like, wait, you 

Preston: mean killing myself as an option? Literally the opening vignette opening being psychiatrist, 

Margaret: the opening vignette of the book is like a scary male nurse came in and told my son that suicide existed.

Like that is the opening chat. Yeah. It's like, what? Anyway, we won't let us know if you want us to talk about that book. 

Preston: Yeah, exactly. So if you're so, so the, the point is that we, we change the system by, by trying to ask it questions and then now we have this like, almost impossible task of trying to predict the behavior of the population.

And, and I think that's like one thing that is most like fascinating and frustrating to me about psychiatry because we have so, such limitations on the tools that we can use and we have like some of the hardest problems in medicine 

Margaret: Yeah. To 

Preston: solve 

Margaret: certainly like I'm, my sister's an oncologist, so I'm thinking, I'm thinking about her, but like.

[00:09:00] There's something. So, because we don't understand, because psychiatry is so wrapped up in people's like personhood, there's also this sense of like, when a parent asks you, what do I do with my child that like had an attempt or like was, was like suicidal and then they won answer and we're like, well we have these, and that's kind of reasonably reassuring, but we can't be like, here's an image, here's a lab that says they won't have another attempt or that they're safe now.

Preston: Mm-hmm. 

Margaret: And that to your point is like so much chaos into chaos in terms of this really important and kind of often tragic question for people. 

Preston: Mm-hmm. And, and it's true for anything. Like even if you show someone that the tumor's removed mm-hmm. They still have to tolerate the risk of it coming back.

Yeah. But we don't give them that tangible reassurance. Like, you really have to sit in uncomfort of the risk and be like very, um, intimate with how powerless you are. 

Yeah. Yeah. 

And, and so that, that sucks, but is also like, I think a growing experience. [00:10:00] But when we return from this short break, we will go over the numbers of who and how people complete suicide and how we can account for those in society.

Margaret: Hey, Preston, what does the sound remind you of? Oh, 

Preston: God. It, it makes me think about being on call. It's the pager. 

Margaret: Okay. Well, it's not my pager, but it is equally stressful as the timer I use for studying. 

Preston: Oh, we got a Pomodoro queen over here. 

Margaret: Do you know what is made studying less stressful, though? What Now, you know, psych, you familiar?

Preston: Am I familiar? I, I use nine Oy for my in-training exams. Are, are we talking about the same thing? That excellent resource that has thousands of questions with associated flashcards, organized content in a user-friendly way. 

Margaret: You use it for pride. I'm using it for the board exams, but yes, we are talking about the same resource.

We, 

Preston: we can use it for both. 

Margaret: Ready to take your exam? Prep to the next level? Go to now, you know, psych.com and enter the code. Be patient at checkout for [00:11:00] 20% off. That's now you know, psych.com. 

Preston: Hey, so I wanna talk to you about this new podcast I think every clinician should be aware of. It's the sepsis spectrum from Sepsis Alliance, and it's done by this great critical care nurse, Nicole Kubic.

Margaret: You may be asking why are two psychiatrists talking about sepsis? But if you've spent any time, uh, in the hospital where psychiatrists or mental health practitioners go, you know that whenever someone's mental status is altered, we can be called and. Not knowing the signs of sepsis, whether that's in the ICU, the ED or other places in the hospital, can mean that we're missing things alongside the team for things that'll really impact our patients.

Preston: Yeah, I mean, delirium comes on quick and fast, and you have to keep it on your differential. It's hit me on the, the inpatient psych floor and mm-hmm. Even for nurses that work in mental health and don't think they're gonna come across this stuff, it, it's gonna come across you. So it, it's important just to, to keep it on your radar and I think this is a great resource for it.

So if you want, you can listen to the sepsis spectrum wherever you get your podcasts, or you can watch it on Sepsis Alliances YouTube channel. 

Margaret: To learn how you can [00:12:00] earn free nursing CE credits just by listening, visit sepsis podcast.org. That's S-E-P-S-I-S podcast.org for more information.

Preston: So when we try to, to figure out who in the population is going to, to die by suicide, let's look at some of the risks here. So, and I know you're familiar with all of these, but I'm gonna play some trivia with you as to, as what the actual stats are. 

Okay. 

So what is the lifetime risk of death by suicide for a man and a woman, respectively in 

Margaret: the US or globally?

Preston: Uh, let's do in the us 

Margaret: Um, I would guess 2% for men, 1% for women. 

Preston: That is very close. It's 1.5% for men and 0.5% for women. Interesting. 

Margaret: I did read that chapter today. I am sorry. I'm ruining your trivia. 

Preston: No, the, the, the point of the trivia isn't [00:13:00] for you to get it right or wrong, it's just, it's just for people to kind of like, think along with you.

This is actually a test, you know? 

Margaret: So, 

Preston: yeah, it's 

Margaret: more fun when I get it wrong. 

Preston: Actually. The, the, the podcast is only successful if I can like, catch Margaret in a lapse of judgment or knowledge that's, we couldn't get any sponsors all this. Yeah. So, 

Margaret: okay. Kind of crazy 

Preston: to think about, right? Like one in a hundred people, 

Margaret: that's a different, like a three times difference.

Preston: Yeah, three times difference. And so now when we move on, let's say, okay, so we have 1.5% of all men. So basically one to two men in a group of a hundred we'll die by suicide in their lifetime, okay? And maybe one of them will be a woman. What about the risk for a suicide attempt 

Margaret: that is 

Preston: lifetime 

Margaret: higher in women?

So, um, maybe 3% of women and 2% of men. 

Preston: It's actually higher than 

that. So it's three to 5% of men and it's eight to 10% for women. 

Margaret: Damn. It's like almost one in 10 women [00:14:00] 

Preston: will have a suicide attempt at some point in their lifetime. 

Margaret: What do you make of the difference between the attempts and then the death by suicide?

Preston: So that's something that we can kind of get more into when we talk about means, but that's like what's a lot of is attributed to that. Mm-hmm. 

So 

men are much more likely to choose violent and higher. Lethality means, and what I'm getting is firearms where women are far more likely to choose something like overdose.

Mm-hmm. Which is one of the least lethal, um, means. So now, now when you're trying to kind of figure out, okay, baseline right men, 1.5%, women 0.5%. Now we have an entire list of factors. So we have gender, uh, which we already talked about. Then we have race, age, socio say economic status, psychiatric status. What of all these things in someone's history and their actions, um, in their life, what is the strongest risk?

Margaret: Of the ones you just listed 

Preston: of, [00:15:00] of, of any of thing that could fall under that. 

Margaret: Um, from like, uh, age, I would think older age. 

Preston: So yeah. The, the strongest risk factor, um, out of all of them, and this is like some this thing that you would see on your, um, board exams or MBEs, is the previous suicide attempt.

Mm-hmm. Which is kind of like, I've always balked at that one a little bit. Hmm. Like, I like, and not that it's not relevant because if I am doing a clinical exam on a patient and I see that they have a previous suicide attempt that kind of like sets off all of my red flags makes me concerned. I've just found that like when we talk about risk factors for anything, and then like the strongest risk factor is that it's happened before you're, you know what I mean?

You want 

Margaret: it to be more interesting 

Preston: than that, but it's like, it's like that for everything, right? It's, yeah. Like the strongest risk factor for heart attack is like a previous heart attack. Yeah. Or the same thing for, same thing for stroke or, or like other things. So it's like. Yes, I get it. But like, is it, so your beef 

Margaret: with it is that it's, 

Preston: it's kind of like a, a [00:16:00] self insistent risk factor on this, you know what I mean?

Margaret: Self, yeah. 

Preston: Yes, dude. Because it's like, it already happened, like obviously, you know, 

Margaret: but like, if someone is, gets pregnant, they're not, it's not a risk factor that they'll get pregnant again. 

Preston: Are you sure about that? Like, are are pregnant women more likely to get pregnant again than other women who don't get pregnant at all?

Maybe, 

Margaret: but not, not in the same linear way. 

Preston: Yeah, I guess I, the, the point is like, I just find it to be like an unsatisfied, I think You think it's an unfun 

Margaret: fact? You're like, this isn't, yeah. There's, where's the creativity? 

Preston: But okay, so, so that's when we know, right. That strongest risk factor for, um, suicide completion.

What is the actual multiplier though? Hmm. So if you were to say, okay, we have a baseline risk, how much does it multiply their lifetime risk by to have a previous suicide attempt? 

Margaret: The original is like somewhere between 0.5 to 1%, 

Preston: I would say. Like mm-hmm. 10 times, 38 times 

Margaret: to die [00:17:00] by suicide or to have another attempt.

Preston: Mm-hmm. In, in, in lifetime. 

Margaret: Wow. Yeah. I mean, and the 

Preston: next, next strongest one is untreated major depressive disorder. Mm-hmm. What do you think that multiplier is? 

Margaret: Mm. Now I'm like, I don't know what to guess. Uh, 15 times. 

Preston: It's about 30 times. Wow. Some are reached in 20 and 30, and that one is actually higher in men or higher in women than it is in men.

Hmm. 

So this one is like really important to us because the history of a suicide attempt isn't something you can change. You can try to modify the risk going forward, but it's like, it's a non-modifiable historic risk factor. Right. But untreated major depressive disorder is something that you can actually modify.

Mm-hmm. 

So these are like some things we really emphasize and target. 

Right. 

So if you think about it like. If somebody has, you know, a 30 x risk of death by suicide in a lifetime, and they have, and it's a man with untreated depression because, because of that, that's like a 30 to like a 25 to [00:18:00] 35% lifetime risk of suicide in someone who just kind of white knuckles their depression their whole life.

That is really high. Yeah. Now all of a sudden, 

yeah, 

you go from one in a hundred to, okay, let's look at just people with depression. Don't treat it. Now it's one in three. 

Margaret: Yeah. Yeah. And then if they had both a prior attempt and that, does it go do, is it additive? 

Preston: So this is where like my math runs into its limitations.

That's 'cause you that try to start, if you try to keep like multiplying these factors out. 'cause they're all based off of like being pulled from the general population. Mm-hmm. It's hard to kind of compound them. Yeah. I actually used cha GBT to like, do do some estimates with this and it, it was like, well like, you know, technically it'd be like 150% chance of dying by suicide if you include all these factors, which is like incorrect.

But if you truncate for reality it becomes more like 50%. 

Margaret: Right. 'cause it's like how many people with depression, like the increased risk is not, they can found lose 

Preston: potency I guess. 

Margaret: Yeah. Yeah. Stats. Stats, statistics. Can we put, I don't know, can we put the Timothy shall [00:19:00] make picture. 

Preston: Um, okay, so, so now going down the line we have um, next highest, which is, uh, substance use disorders.

Yeah. Active substance use disorders. Yeah. What'd you say that multiplier is 

Margaret: 20 times? 

Preston: Yeah, it's about 10 to 15. I thought I got 

Margaret: exactly right. 

Preston: Yeah. So now I'm, I'm just gonna kinda go rapid fire down the rest of them. So we have access to firearms. This is another big one that we target a lot. Mm-hmm. This increases the risk by about five to 8% in men and three to 4% in women.

Then we have social isolation about a four times multiplier unemployment, three times chronic pain, childhood trauma, family history, all about two times. Mm-hmm. Multiplying your risk. Mm-hmm. And then we have active bipolar disorder 15 times. Yeah. So it's like on par with depression and, and substance use 

Margaret: With bipolar, the increase, the risk is more increased in depressive or mixed states.

The mania, 

Preston: it's the highest in mixed states. 

Margaret: Yeah. But that was just an aside, um, that Yeah. Like [00:20:00] versus mania. 

Preston: Fun fact for pr for pride. Yeah. Yeah, yeah. But like many people are less likely to die by suicide. Yeah. And, and then also people with major dere or bipolar disorder spend much more time in depression than they do mania.

Yeah. So. Like time, time under tension. Mm-hmm. I guess for, for that. Um, gives them more exposure to that risk. Then, um, schizophrenia is one that's really interesting. Hmm. So it, it has an eight to 10% risk that's like often listed in textbooks. I was actually listening to the podcast, um, the Psychiatry Bootcamp podcast with Dr.

Tyler Black. 

Margaret: Yeah, 

Preston: yeah. Super good podcast. But one of the things he brought up in, in there don't, you're not 

Margaret: gonna shade. Okay. What what's the but 

Preston: Oh, sorry. And, okay. Super cool podcast. And one of the things that he brought up, there's no, there's no, no buts here. This is our first podcast 

Margaret: Beef, our first enemy of the pod.

I think one of their producers messaged me actually and was like, Hey, we love your pod. So. 

Preston: No, I really appreciate Tyler Black and, and he, he talks a lot about like the [00:21:00] Dirk he criteria too. Mm-hmm. Anyways, he was bringing up how the risk of, um, suicide and schizophrenia decay throughout your lifetime. The longer you spend in, like with the psychotic illness, the less lifetime risk you have.

So it's like that eight to 10% is right. Is very proximal to the diagnosis, but then over the lifetime with schizophrenia, it comes out to be about 5% the longer you survive. 

Yeah. So, 

which is, he was saying that actually math textbooks will like, use this statistic we have like the 10% risk of death and by suicide and like use it to mock physicians as to how bad we are at math.

Margaret: Wait, what? How Well I guess I'll listen that podcast to find out. Yeah. 

Preston: It, it's, yeah, it's because we don't. We don't take into account that like the, the risk is dynamic and it's changing as people like age out. And we just took this study where we, we looked at like this amount of people with schizophrenia die by suicide.

Mm-hmm. And said 10%. Mm-hmm. Then didn't take into account that like a higher rate die earlier on in the diagnosis and a lower rate die. 

Margaret: Yeah. 

Preston: Later on. Yeah. 

Margaret: I mean it's kind [00:22:00] of like the, like substance use one that it's like, is the reason that there's a higher rate among like opioid and alcohol users?

Like I, based on what the substance does, based on clinically what I've seen and like knowing kind of the overview of the land, like that statistic could make you think like, oh, they, there's like the same effect, but the reality is mm-hmm. That those would have much different effects that could end up in the same kind of 10% whatever.

Yeah. That increase two 

Preston: very different roads that lead you to the same outcome. Yeah, exactly. Um, and then kind of now moving into the other like. Lower impact factors, but still, still important. So we have PTSD personality disorders and, um, L-G-B-T-Q or like gender dysphoria all around, like somewhere between like the two to 5% factor range.

Mm-hmm. We have traumatic brain injury and then we have older age all around like one to three. Yeah. So, so when you look at someone and you say, okay, they're, you know, a white male in their mid [00:23:00] sixties mm-hmm. With, you know, a family history of suicide, traumatic brain injury, and, you know, traumatic childhood, those are all gonna like, greatly increase the risk for suicide 

mm-hmm.

As you kind of multiply it up, but you can't change any of those. Right. 

Right. 

And that, that kind of gets into the, the part of like, okay, how do we actually like this person's at a high risk, I think, you know. Mm-hmm. Maybe they have a lifetime risk of 10%, but how do I predict what's gonna happen right now?

You know? Right. I know. Communicated so to kind of Yeah, exactly. So to reference the weather prediction earlier. I know that it's probably gonna snow in Boston sometime this winter, but I don't know if it's gonna snow tomorrow. And I, and like, it's really hard to predict that. 

Right. So 

we, so we know there's a high risk of them in their lifetime dying by suicide.

Yeah. But it's hard to tell Yeah. Right. Now do they need to go in the hospital or not? Which is often the choice that we have to make. 

Margaret: Which does feel like similar to kinda the pe the feeling people describe with like terminal cancers that are like cancers that they're like, [00:24:00] okay, you're in remission now.

But I mean, I think that like, right, if you're, if we're seeing someone in the emergency department or if we're talking about this in depth, like this is kind of active for them. Um, it's kind of like, we don't know when the next like flare will attack again. It's, or like with like a heart attack, it's like, yeah, you're now at higher risk for this to happen again.

Here are some things we can generally do to help it prevent that happening. But you're also just at heightened risk. 

Preston: Mm-hmm. 

Margaret: Regardless. And we can't tell you when it's gonna happen again. 

Preston: Yeah. 

And I think that's actually similar, like where us in cardiology have like very similar approaches where the cardiologist then says, okay, but I know if you're, if you're on a blood thinner or like mm-hmm.

Um, an antiplatelet medication that's gonna reduce your overall risk. 

Yeah. 

Or on a statin or something like that. So, so we can modify those risk factors, but we can't modify the fact that you have a family history of a heart attack or those other things. And, and so now to kind of like look at the impact of these interventions we have, you take someone who, like a male who has depression and access to a [00:25:00] firearm, just those two factors alone 

mm-hmm.

Increases their lifetime risk to about 40%. Hmm. We have, we have an eight times multiplier for owning a firearm and like up to like 25 to 30 times for untreated depression. So if you as a psychiatrist treat their depression mm-hmm. And remove their access to their firearm Yeah. You can, you can reasonably reduce their big risk reduction, lifetime suicide risk by like 30%.

Margaret: Right. Right. 

Preston: Which is a really substantial number. It makes a big difference. 

Margaret: And I think it like, gets at something that is, is not something I necessarily think about every time I do a risk assessment beyond like if someone's had like attempts in the past, but this idea of all of these things, we should talk about all of them and make a safety plan for like reducing all the modifiable things, but like actually knowing the numbers that you're saying of okay, but this harping on the firearm may be, at least with the knowledge we have now, maybe like way more effective [00:26:00] compared to harping on the thing that might change their likelihood two to three times down.

Preston: Yeah. And, and like we can't make these like perfectly need extrapolations from these population data, data sets. But it actually was so helpful for me to kind of look at the impact factors or effect sizes of them because, so for example, when I'm doing, I don't know, do you work in a va? I. 

Margaret: I did in med school, not here.

Preston: Okay. Yeah. So, so we have to do all these like comprehensive suicide risk screeners, we those, and make these assessments. Yeah. And it is just like unlimited check boxes for all of these risk factors. Mm-hmm. And you just kind of check them off willy-nilly and you're like, okay, um, you know, TBI, older age male access to firearms.

And it's like, you know, we have like small, small effects, small effects, small effects, small effect, huge effect. Mm-hmm. You know, like, yeah, he's unemployed and he has chronic pain, he is not housed. Like all of those have like a one to 2% effect on it, but, uh, but also he has untreated depression and, and a gun and access to a firearm, you know, and [00:27:00] it's like, okay, if you only focus on two of those factors, right?

Like you are effectively reducing the risk way more than any of the others combined. 

Margaret: Right. It's like the use of like, I think for like primary care doctors, right? That there's not how you triage the time you actually have in clinical care with someone. It's not like we have a. Always endless time to spend with people, even in these settings where we maybe wish we would.

So like, how are you gonna use that time? Are you gonna use it on the one that's gonna reduce it three time, or like, go down from three to 1%? Mm-hmm. Or go down from 30 to 1%. 

Preston: And also like the amount of effort you put into solving some of this chronic pain is probably not gonna get you a lot of output. Uh, well, I like, 

Margaret: I'm in chronic pain, so I'm like, no, but yes, you're right.

Yeah. Sorry. 

Preston: Well, I'm referring to like, you know, emergency department at, at two, I'm gonna pain problem at two in the morning. I'm gotta, guys, I'm gonna reduce the chronic pain. And also I'm gonna like, we're gonna do 

Margaret: some ccbt speed run right now. I'm gonna build 

Preston: you a house and buy you a, I'm gonna build you a house and get you a job.

Margaret: It's gonna be a whole thing. 

Preston: Yeah. So. But kind of taking [00:28:00] that part of how we modify these risk factors, when you kind of think about employing population safety. Mm-hmm. Taking into account how people die by suicide is really important. Yes. So just like how we talked about re removing the firearm from the home makes a big difference for people.

And you know, we see that like death by firearms. I don't have the numbers for this, but it's much higher in the United States. I actually do have, than there is in numbers countries that don't have access. 

Margaret: I have the numbers for this. I think, oh, 

Preston: okay. 

Margaret: Well wait, I don't have the direct numbers, but one thing that was interesting and statistic, they were talking about this in this chapter in the, um, Kaplan and SADS comprehensive textbook of psychiatry.

It's a new version, but they looked at the data for suicide in between 20 2020 19. And the global age standardized rate of suicide has fallen 36%. But in the US in that time period, it went up 17%. Oopsie. And the thing that. One of the things that they were talking about beyond like the most common methods, which like in Europe [00:29:00] is again, not basically everywhere besides like the Americas, like in Europe it was like hanging others.

It was like self poisoning suffocation in Africa and Latin America and Asia. Um, but one of the things was like, they mentioned specifically a time like, like just they mentioned the, what you're saying of like where there is less access to guns. Um, the method changes, but also it looks like a correlation in terms of the amount and like why it's gone down everywhere besides the us.

Preston: Yeah. And that brings up a, a really interesting fallacy that people, um, think about with suicide, which is if you remove the means, people will inevitably find another method. Right. What we find is not true. Yeah. When you remove access to the means, it reduces the overall rate of suicide. Mm-hmm. Period.

Mm-hmm. 

Mm-hmm. 

So when I was kind of actually studying a lot of these methods, I was finding that when countries would like employ new policies or barriers to accessing that method, they [00:30:00] would see drastic reductions in their suicide completion. 

Yeah. 

One really interesting case study of that was in Sri Lanka in like the 1990s and early two thousands.

Mm-hmm. Are you familiar with this? 

Margaret: No. 

Preston: So they would, um, they had a lot of access to pesticides out these like rural farmers. Yeah, yeah. You know, like, like SAR and gas acetylcholinesterase inhibitor type situations. And so they would take these organ phosphates and they would overdose on them. So I know we mentioned that overdose is the most common form of suicide here in the US People are diet of rate of about two to 4% with overdoses in, um, developed countries.

And it's usually with Tylenol. 

Mm-hmm. 

But if you overdose on organophosphate or one of those pesticides in Sri Lanka, the death rate is like 60%. Right. 

Margaret: So there's a much higher, it's 

Preston: extremely effective. So actually Sri Lanka in like the late nineties and early two thousands had like one of the highest rates of suicide in the world.

Hmm. Wow. So they, they banned all access to the pesticides. Yeah. 

Margaret: Yeah. 

Preston: And it saw a huge drop in the amount of completed suicides. 

Margaret: [00:31:00] Yeah. Well, related to this, I think the one I had read about that was like another public, like structural thing that gets at this point was. I think it was in like the mid eighties, early nineties when there was a, like a more strict, um, prohibition on alcohol within USSR.

Mm-hmm. And that they saw a huge drop similarly in like death by suicide, suicide attempts that were documented. Um, and while the alcohol wasn't the thing that was the poison or the the means mm-hmm. It was, it gets at this point of kind of like impulsivity. That is part of, we talked about this last time where you had mentioned it, of the kind of like the final burst to actually have an attempt.

Um, and if you think about the combination of like structural things like access to alcohol or access to highly lethal means. 

[music]: Mm-hmm. And 

Margaret: if you remove those different elements that people need, then you make it much more difficult to, [00:32:00] you make it less likely that the impulsive moment is gonna happen with access and like that the impulsivity will be there at all, which I think is interesting.

Preston: Yeah. You remove both the gasoline and the flame 

Margaret: mm-hmm. 

Preston: At the same time. Yeah. And, and it's like, it's always been so fascinating to me how we like do these really thorough population, um, studies to come to the conclusion that like if people have less access to dangerous things, they're less likely to hurt themselves.

Margaret: Yeah. 

Preston: It's, it's always like so funny how it comes like full circle, these I things. Yeah. But, but another like, great example of that is, um, with nets on bridges actually. Yeah. So falling used to be a really high, like very common way that people die by suicide. Mm-hmm. And then a lot of like the, um, golden Gate Bridge is like one of the leaders, there was a very famous one for suicide, I think.

Um, they've had like hundreds if not thousands of attempts, and I think only 20 people have survived. Yeah. From the Golden Gate Bridge. Wow. It's a very [00:33:00] lethal place. Yeah. Same with, um, like the Coronado Bridge and other places. So they, they just introduced all these nets and. Sees giant drop in suicide rates.

The same thing in like a lot of Asian countries. People would die, um, by jumping in front of trains. They introduced different kind of barriers or things that prevented that, and it made a big difference for them as well. And, and those are all like kind of examples that refute the, oh, someone would just find another place to jump.

Like we put a net in the golden, we spend millions of dollars putting in nets under the Golden Gate Bridge. Why don't they go jump off this office building? But, but they don't. 

Margaret: Yeah. Well, and I think the underlying incorrect assumption is that people who have suicide attempts or die by suicide, that it's because they've been, it's this like stereotyped image of like, they have been depressed for a long, long time and have this persevering like desire to die and will find it at any means.

And it's like there are people mm-hmm. Like that, like in the population for sure. But there are also many people who, something like we talked about in the last [00:34:00] episode, something happens. There's a sudden loss, there's an alteration mm-hmm. In your physiology. Mm-hmm. There coping still skills are overwhelmed.

Yeah. Yeah. Um. And if there's an option right there, then it's like a lot easier just to act on it. Especially if it's something that, 

Preston: A commuter bridge. 

Margaret: Yeah. 

Preston: Something that you're traversing literally anyways. Or something 

Margaret: instant too. 

Preston: Yeah. Um, so this was really fascinating to me. We had, um, one of the survivors actually, that jumped off the Golden Gate Bridge, came and talked at my 

Margaret: Oh, wow.

Um, 

Preston: university and I, I wasn't familiar with psychiatry at the time, but he was talking about how he, he became pretty depressed, Uhhuh, and he started hearing voices, and the voices were telling him to do things, and we were all kinda like, wow, this is so weird. And looking back at it now, he, you know, we had, um, major depression with psychotic features that was kind of leading him to act like this.

But even with like how severe his illness was, he said like, without a doubt, the second that he. His feet [00:35:00] left the platform and he jumped, he regretted it. 

Yeah. 

Like this, like as he's like going towards the water, every ounce of his being was like, I wish I wouldn't have done this. 

Yeah. 

And what was really fascinating, I, I didn't verify this, but he, he shared it with me.

He said, you know, 'cause I think he met with the other survivors from the, the Golden Gate Bridge. And it's like a, a pretty small coie of people that have done this. It's like under 20 Yeah. I think are living right now. And there's, it's 100% across the board. Wow. Every single one of them regretted it when they jumped.

Margaret: Yeah. Yeah. Which gets to the point of the, 

Preston: it's, it's impulsive and it's uncertain and it's scary. It's not, you know, I've made up my mind and I'm just gonna keep trying until I die. 

Margaret: I know we talked about like, not to harp on one example, but like the White Lotus episode in the recent season. But I do think their depiction was, you know, dark and is hard to watch, but also like.

The uncertainty that he kept, the dad kept having these recurrent [00:36:00] dreams of like ways that he would, you know, spoilers, whatever, you should know this right now. Mm-hmm. We've already just spoiled it like he would die or his family members would, you know, and I did think that like iterative imagining and, and having like dreams and uncertainty is more, is, is more realistic for at least a good portion of patients I've seen who struggle with like suicidality.

Mm-hmm. Or have had a suicide attempt in the past. 

Preston: Yeah. It, it's an act that occurs under extreme tension. Yeah. 

Margaret: Yeah. 

Preston: From a, from a lot of different directions. So I know we didn't talk about the numbers for the, for the means of, of how people die, but just to kind of put them in reference, um, the number one or the most lethal method that people try is via firearms.

And that has an 85 to 90% completion rate, which is, is honestly unbelievable. And it's, it's. Nearly, um, 50% higher than like the next closest, which is like jump either jumping from height [00:37:00] or um, carbon monoxide poisoning. But even carbon monoxide poisoning is going down because we've introduced catalytic converters and we've put filters on gas stoves.

So people are less likely to die from that. So when you look at the most common attempt being like overdose Yeah. Which is like two to 4% rate of lethality versus 90% with firearms. Right. It can kinda help you understand why even though men attempt much less, they um, have a much higher rate of completion.

If you look at the overall suicide, um, 

victims via firearm, 87% of them are men. 

Margaret: Right, right. And I, you know, I know we make, right now it's June, it is Men's Mental Health Month. I know. I make jokes. But I do think there's also something about the, like, why do men use more lethal means? And there's a lot of things you we could talk about with that.

But I also just, you know, [00:38:00] the ability for men to talk about their emotions and their struggles and have it be heard. And that to me it feels like there is a connection between choosing a highly lethal method and the like terror that a lot of boys and men have been raised with, of being able to talk about feeling ill or feeling weak or feeling really depressed and down.

Especially if that's not something that they've seen someone get help for or had, like friends or family members show it's possible to get help for and not be shamed for. 

Preston: Yeah. Um, I, I, I can only kind of guess why I think that there's a lot of, um, anger and hatred. Self hatred 

that kind of goes into, uh, like depression with men.

Yeah. 

Often like people, it's hard for men to express these like feelings of like hopelessness or sadness, and it all just kind of gets repackaged as anger. And when you're angry, you wanna destroy things. I think [00:39:00] part of it's is like this kind of 

desire to destroy yourself, it leads people to use like a lot more violent means.

Yeah. And yeah, I, I'm not sure why. 

One thing that was interesting to me as I was kind of reading about, um, some of the statistics were the, the states, the US states that have the highest rate of suicide per capita. And they were all these, um, states with low population density and um, like high rates of isolation, alcohol use, and access to firearms.

So it was like the, it's like Montana, Utah, Alaska, Wyoming. Pretty high up, and I guess it makes me just think of like someone who's like isolated and alone. 

Margaret: Yeah. I mean, that's one of the elements. There's also the elements of like what is the government structure and support one of like, there are more populated for the ones I think, I know New York and Massachusetts we're in, [00:40:00] um, the top, like the five with the least, and they are more populated.

Mm-hmm. There's also, at least in speaking for my state in Massachusetts, there's more government involvement in terms of like having a broad mental health safety net system. Um mm-hmm. Just to, to add that, I think you're right in terms of the loneliness, but I also think that there is, there's possibly also a component of what are the structural things that Yeah.

Impact those numbers. Yes. And yeah, 

Preston: and like any chaotic system that we're studying, it's so hard for us to tell what's causing what. We just know that when this factor is present, this outcome 

is not, yeah. And vice versa. So in, in summary, 

we have a lot of different ways that people may attempt to take their own life, and it's hard to necessarily figure out who we have these risk factors that are modifiable and non-modifiable.

What we do know is that when you institute [00:41:00] laws that restrict access to these means, it changes outcomes and either putting in nets under bridges, areas in front of trains or gun safety laws and they end up being suicide safety laws. Right? Yeah. As, as far as the, the completion of suicide is concerned.

We're gonna take a quick break and then when we come back we're gonna kind of talk about how do you address this with the patient in the room mm-hmm. And go through the fabled safety plan. Yeah. That need spend a lot of time talking and agonizing over. 

Margaret: Yes. We'll be right back.

We are now gonna take some of the things we've talked about that are theories and numbers and research on this, but take it into the clinic. Um, we're gonna cover, we're 

Preston: gonna distill entire life stories into bullets. 

Margaret: Yeah. 

Preston: And paperwork. 

Margaret: We know psychiatrists and we know you love numbers, [00:42:00] so that's what we're about.

I do, I miss, I kind of miss math sometimes in psychiatry. Um, so I did not make a mnemonic for this, but I did give us three steps to thinking about it that I think can apply an outpatient where sometimes I think this is a little bit actually harder because the, the fact that someone has been either brought into the ED or brought themselves in says something I think, not that you will say they need, definitely need hospitalization.

And there's still like a lot that goes into that. But that. Elevates the level of kind of seriousness and concern that we should have. If someone is or been brought into the ed, someone in their life or they themselves were so worried they could not stay safe at home, that they came to the ED in a lot of those cases.

Mm-hmm. In outpatient, it's not as clear it, it doesn't have that indication. And we also, when we think about treatment, especially for folks who have maybe had depression for a long time or they've had chronic suicidality, but like they have never had an attempt, all these risk factors we just [00:43:00] talked about, 

Preston: they just kind of float in the ether.

Margaret: Yeah. And it's like we don't have this Pollyanna view of inpatient psychiatric hospitalization, that it's necessarily the balm for every single person that would go there, or that more importantly maybe that disrupt pulling them away from the other parts of their life and all the different kind of socioeconomic factors of that could include, will make life better and make the depression better.

Um mm-hmm. So my first point is find the story, which I, why did I make these so cheesy? I did. Um, so I think the first thing when we think about like patient interactions or when, when I see a, any of my patients presumably, um, we're talking about cases where something has changed or emerged about their suicidal thoughts, planning actions, self-harm, substance use, some of these risk factors we've talked about, right?

And so I always think if someone brings that in, often my patients will like bring that in and kind of say it in the outpatient setting [00:44:00] of like, I've been struggling more with this first finding their narrative they have, as well as things that have changed in terms of this chaotic system. But there's not always a clear cut pattern.

But often when people are in this really acutely depressed state or in crisis, it's hard for them to see any patterns that can actually. Help bring some comfort in terms of like, am I always going to feel this depressed or this dysregulated? Um, so first just getting their narrative and then also kind of being the executive function sometimes in the room when they're in a crisis state can be really important and is clinically important in terms of you'll start hearing some of these risk factor parts.

Preston: So, so it's like identifying where the emotional turbulence has kind of thrown them from their baseline. 

Margaret: Yeah. 

Preston: And and trying to, to establish like what's leading them to this moment right now. Yes, 

Margaret: exactly. And like there, there, like, I wanna say there are some people where it will, for whatever reason, like the crisis or the change in [00:45:00] depression or the bipolar mixed state has emerged without any changes across all these different domains.

I'm about to kinda list. That those people do exist, and that's always an option. But I also think that there are often changes that impact these other risk factors. And so we don't wanna just say like, be bio essentialist in some ways and like, oh, we, we know nothing about these other parts that impact it in this chaotic system.

Mm-hmm. Um, so beyond like the depression getting worse, or like bipolar illness getting worse, I think some of the main things that I will elicit from people for their narrative around this. So if you're, you're an outpatient, right? You've, you've started outpatient this year. Mm-hmm. What are some of the things you ask about?

If I came in, actually, we're gonna do this in the case, so I'll, I'll pull it back. Um, big things that relate to your risk factors that I ask about if there's someone, anyone asking about substance use, but especially if there's someone who has a substance history in the past, even if it was [00:46:00] like a. I'm seeing a 40-year-old patient and they're like, oh yeah, I struggled a little bit with like alcohol when I was in college.

But that hasn't happened in a long time. Like kind of a pan review of if they're coping mechanisms that they use or have used in the past and felt over reliant on, have changed is something that informs me in terms of one of the ways of how much they're struggling. Um, another part is being thoughtful around medication change timeline.

I think if you changed a medicine one week before, you might be like, oh, this is doing something or making something happen. Right. But what can happen in outpatient especially is like. You decide to taper da like cross taper from Lexapro to another SSRI. 'cause they're experiencing side effects. And then someone misses an appointment and they were supposed to see you a few weeks ago, but they haven't seen you, whatever.

And suddenly they were on Lexapro, let's say like 20 milligrams, like a high dose, and they've been living at Lexapro five now for two months, and you've decreased their prior somewhat effective depression medicine. So, 

Preston: mm. Just 

Margaret: being [00:47:00] very thoughtful around not just immediate med changes, but like, are they, it can be easy to kinda lose sight of those, the, the changes that have happened slowly given that we don't necessarily see the impact on mood disorders for a while until they're off the med.

Preston: Yeah. It's really interesting to think about like, while we're trying to treat someone, we temporarily can introduce some instability. 

Mm-hmm. Mm-hmm. 

You know, we're making, we're making a med change and then that kind of, it changes the status quo and it, and it can change people's, uh, coping skills and also the amount of distress they feel.

Right. 

Margaret: Right. Exactly. Yeah. Um. And then I think changes other things, like a couple things, relational changes. So not just like someone's going through a breakup or grief, but like people changing, like part of life they're in, like someone who's been like a stay-at-home mom and her last kid is now off at college.

Mm-hmm. The marriage relationship is okay, but sometimes not great. And she's not necessarily involved in the community. [00:48:00] So how populated is that? Like 

Preston: retirement? 

Margaret: Yeah. Like how populated this person or someone who's like post grad and they just moved to a new city where they don't know anyone and they're an intern maybe or one of our listeners.

Um, and they don't really know anyone in the city and they're working all these hours and they're stressed and there's not a lot of close relationships around them that they feel connected to. So just how is their relational world peopled or become unpeopled in some ways and like connections on many different levels to that.

Um, and then the last thing that I think about as well is. Like lifestyle factors. I think this gets underestimated sometimes. Like it's not like getting one bad night of sleep is gonna make someone's suicidality risk go way up. But like if they are suddenly struggling with insomnia in my postpartum patients, right.

If they're now not sleeping, 'cause they're waking up constantly to feed a colicky baby. Um, we know, and we've talked about how exercise and mild to moderate depression can have this near mm-hmm. The same effect size as like an [00:49:00] SSRI. So if someone has had, got, had an injury now has pain and they haven't been able to exercise just all of these things and helping us figure out the story even if we aren't super certain, I do think having a story in and of itself can be protective to be like, well we can change these things and have hope around changing them.

Um mm-hmm. Versus to use your term like kind of total chaos that we have no impact on at all. 

Preston: Mm-hmm. 

Margaret: Um, the second thing I would say is I put, run the scales. I was in a mood when I wrote this, um. I do think that pairing the narrative with the kind of psychometric data is super important, especially in, in inpatient, in the ed, but in outpatient in terms of like, where does someone sit with their, like PHQ nine or with their like GAD seven, like where did their symptoms sit in terms of if it's worsening, um, as well as then the suicidal risk factors.

So there's a number of ones that you can do. I know you mentioned one, [00:50:00] we, this wasn't explained to me until like a year ago, and maybe I just didn't get it, but I'm gonna say it for any listeners who also maybe, so the baseline Columbia suicide screening, um, scale, and then the A SQ that asks suicide screen questions.

Both of these are screens. We know this from med school. Again, this, Preston, you probably understood this from the jump, but my brain was like, what? Those ones let us know if we need to explore further as screens and then. For my institutions, we use the, like a suicide risk assessment that basically talks about all the modifiable, um mm-hmm.

And non-modifiable risk factors and prior acts and self harm and other kind of diagnoses and that we do if they screen positive on these other two. So, mm-hmm. Considering, so from like the data, considering if you're in an institution that regularly collects it, where are they at in terms of the symptomology of their depression?

Bipolar is harder to measure, but depression, PTSD and like [00:51:00] anxiety, I think about, and then also like doing the stepwise assessment for the risk factors and documenting all of that and all of those things. So pairing that, I think that's also just important from the bias perspective. Like there is a lot that can come out.

This could be a whole episode, which so we won't get into right now, but like in this chapter I was reading in the textbook, it was like, I. Sometimes clinicians can feel countertransference towards patients who express suicidal ideation. And I was 

like, they could feel this, this, and this. It is literally, there's a sense like it is called countertransference.

Um, so there's a lot there that we won't go into, but I think pairing the narrative with some of this subjective questions, but more repetitive data over time gives us a more robust picture and also doesn't make the patient feel like we're either being like, okay, answer these questions and if you answer it in a certain way that I'm gonna send you to the hospital or not, whatever.

Um, [00:52:00] do you have any other ones you think about for like the psychometric data? 

Preston: Um, when I'm trying to assess for suicide risk? 

Margaret: Yeah. Or when you're like, let's say you're in an outpatient encounter and you've done the, the suicide kind of risk stuff. Just, and, or I guess is yours different in terms of the float workflow?

No, 

Preston: we, we use the same like psychometrics. Um. I don't know. I, I, I can't, maybe I don't take advantage of psychometrics as much as I, I should or I could. I, I think I tend to not put a lot of value on them 

mm-hmm. 

Because I, I see them as like screeners Yeah. From the start 

Yeah. 

Which lead you to do more investigation, but like, I'm doing that investigation right now Right.

While I'm talking to them. Right. You know, so, so I see their utility in like, you know, attached to a clipboard in the waiting room. Mm-hmm. Um, but not necessarily as much like in the 

Yeah. 

Like in the visit. And I think this is like something that I've kind of gone back and forth on too. Mm-hmm. Where like PHQ nines are really effective at screening for depression.

Mm-hmm. But then a lot of studies will use PHQ nines to trend [00:53:00] to depression or try to like mark like treatment recovery. Yeah. And that's like not nearly as accurate. I 

Margaret: think. So I agree with you. I guess ours in my system, it's sent over Epic before the visit as like, please fill this out before your visit.

And then I have like a graph as a dot phrase that auto-populates. 

[music]: Mm-hmm. 

Margaret: So. It's not a lot of like legwork for me. It's more like I can look at this and if they went from like they've been at 4, 4, 4, 4, 4 on like the GAD seven and now suddenly they're at 20, like, I'm like, okay, good. Mm-hmm. And I, I do think there's something about that.

It's the same each time in terms of chances of at least giving us something to reflect on and to in Yeah. You, 

Preston: it's showing you an objective huge shade from their baseline. Yeah. 

Margaret: But it's like questions, if I just send asked to everyone or have them fill it out, that would, I would be way less incentivized to use that data.

Mm-hmm. But I do not. Yeah. That makes sense. Um, and then the last thing before we do our couple case examples that [00:54:00] Preston is gonna be. I'm a brave psychiatry resident and I'm gonna be the patient. Um, is just, is, so we said find the story, which is like the narrative part and get the metrics, which is the kind of numbers objective, anti-bias part.

Um, as well as in that is sort of the like, legal and billing is these requirements of that part that they wanna see, which I think is actually fair in this case. And then the last thing is increased level of support in, in most cases, and that we can be creative with that. In an ideal world, there would be a continuum of care all like from an outpatient clinic with increased access to see you like weekly instead of once a month to be able to connect with social worker or like an RN who can check in during the week, um, you know, to partial programs, virtual or in person to residential inpatient.

In an ideal world, everywhere that would be possible. That is, I'm from a college town and not Boston, so that is very much not possible everywhere. Mm-hmm. I, I do think this is where the cliche, don't worry alone [00:55:00] comes in, um, especially don't hold the risk alone in outpatient. So increasing seeing you and then possibly getting, thinking about like what is your clinic or practice setting that you're in, what are the other things they have for this kind of, that is like one of the benefits of being in a group practice or an institution is that there is more like of a mm-hmm.

Standardized way of how do we hold people when they're more acutely sick and they aren't hospitalization level yet. 

Preston: One thing that that's really cool that my program does is we have this thing called the living room. Hmm. Which is like, it's just like an open, basically like coping station where it's got like, um.

Aromatherapy. It has couches, it has like games, journaling, things like that. And it's staffed 24 7 or like, not 24 7, but like during all work hours by a psychologist. Wow, that's awesome. Or like a psychology, um, like intern. Mm-hmm. So at anytime if someone feels like they're in crisis, but they're like not at hospitalization level, they go to like our living room and then they just [00:56:00] kind of sit and they cope with them.

They walk them through exercises and do different things together for like 90 minutes, two hours. They kinda like continuously check in and then they make crisis response plans or safety plans with them. That's cool. 

Yeah. And if 

they need to, sometimes they go into the hospital, but sometimes they just kind of go free from there.

Margaret: We have, we don't have any. That's awesome. First of all, like that feels like this kind of creative continuum of care that offers these kind of in-between spots so people don't have to go into the hospital if they like. Not indicated, or it's just like really, like not been helpful for them in the past.

Mm-hmm. We have like an urgent care psychiatry clinic that we do that is like, walk-in. Um, and that has, has social workers for like, emergent, kind of similar, not therapy, but just like this person doesn't have care, can't be seen by, by someone, their psychiatrist today or their therapist today. Mm-hmm. And that has been a really cool model that has only come into existence in the last like few years, [00:57:00] I think, for us.

Mm-hmm. Um, so besides increasing contact, there's also getting a little bit more aggressive with your medication. Um, management, we know if someone's like struggling with depression, like classic depression, SSRIs aren't really going to help from a physiologic standpoint in the first couple weeks. But you can create a more aggressive plan, like maybe in a, in a, like someone's doing fine, but they, they're having this side effect.

On their antidepressant. Maybe that taper looks slower to avoid side effects, avoid whatever. Maybe you get more aggressive in outpatient where you're like, I'm gonna see you in two weeks. I'm gonna increase the amount of times you see me. We're gonna come down by this amount this week, and then the next week I want you to come down by this amount without me.

Like I won't see you in the, in between week. And then we will start the other one. So like, increasing the timeline to a certain extent as much as is possible, um, when they're outpatient, as well as considering more use of like, as needed medications depending on their diagnosis. So like if they're having [00:58:00] panic attacks, if they're really struggling with sleep as part of their illness, and it's not like mania, but it's like part of depression, like 

[music]: mm-hmm.

Margaret: Freeing up your ability to use benzodiazepines or sleep medications or other things like that to get through this crisis period. Um, so protecting the, the lifestyle factors that we talked about earlier that can further destabilize 'em. Um, and then the, the last thing just, you mentioned this a little bit with treatment.

For acute kind of studies on acute forms of like CBT and DBT have shown like to be effective in reducing suicide attempts. There's also been some studies in psychodynamic and like family therapy and interpersonal, um, that have had like rrc TS for effectiveness. Effectiveness. The other thing that they said in the chap in the textbook that I just thought was interesting before we do the cases was there was a, a heading in the chapter that was like supportive calls and letters after discharge from the ed.

Mm-hmm. Um, [00:59:00] which kind is like, yeah, support is good, but one of the things they mentioned in the, in the text was thinking about how different forms of technology or apps or like well-rounded care could exist in that way of connecting through like a health app or with like health coaches or things like that.

So I just, I thought that was interesting and that, that was, they've done studies on like. Places where they reach out after discharge and like with a phone call, whether from the clinician or from like an RN or an MA or other like integrated care that found it to be somewhat protective and like reducing the loneliness.

And also that, that kind of factor we talked about last episode of suicidality, of feeling disconnected from people in the community. Um, and that even five minute like phone calls were found to be useful. 

Preston: I wish we could prescribe friends. 

Margaret: Maybe the real antidepressant was the friendship we made 

Preston: along the way.

No, but yeah, like go pick up your friend at, at the pharmacy [01:00:00] and they're gonna genuinely be invested in your life and hang out with you and do things like if that, is that something we could prescribe? It'd be such a protective risk factor, 

Margaret: right? No. Yeah. I know. I know sometimes I get like, not when someone's super actively in like acute depression, but I do think sometimes I.

Speaking to these kind of studies on like lifestyle factors and belonging in community and pushing our patients a little bit more in that and using our like, power that we have in this system to help legitimize, like, no, that really, I know you know it, but like, what are ways we can think about this? And I'm gonna put it in my note and ask you about it in two weeks when we check in and see how it went.

And if it didn't go well, that's okay. Mm-hmm. Like, we'll try something different. But I do think we have a role actually in like helping to remind people not know, like, you should exercise. It's good for you, but actually, like, they're in crisis, they're depressed, their thinking is not as clear. We can help with that.

Mm-hmm. 

Preston: I try, I try to like, [01:01:00] make people, if they don't have hobbies, I, I push my hobbies on them. Not, not really, but I'll be like, I'll be like, oh, do you like walking? Like, what about this walking group? And I'll like, I'll like, like, I'll like look it up in front of them. Be like, they're near your house.

Like. How about that as a goal next time? Mm-hmm. Just, just attend one walking group. 

Yep. Yeah. On 

this day. And like be very, very specific about it. Not like you should walk more Exactly. Or something like, no, exactly. I want you to go to this walking group and tell me about it. And like maybe helped to be like less paternalistic about it.

Mm-hmm. Because then like they go and it sucked. Like I hated it, you know? But you want it to be like their idea. 

Margaret: Yes. Yeah. So I 

Preston: try to be like, keep it open, like what's, you know, what's the thing you could do? Okay, how about this? What are your thoughts about that? 

Margaret: Yeah. 

Preston: But sometimes when people don't have any motivation to try anything then, then I'm kind of just like, ah, you know, you can hate me if, if it sucks, but try it at least.

Margaret: Yeah. Yeah. I mean also it's like if they're super depressed and like there's like, you know, very strong anhedonia la like fatigue [01:02:00] a motivation. Definitely. This isn't the right approach. I'm not like dropping. Gimme 20 exercises. 

Good for your depression. Get out of my clinic if you don't wanna show up.

Preston: Yeah, I'll see you at the gym. I'll 

Margaret: see you. Yeah. Um. But no, I think the getting specific, getting creative for, with people and also the like, to the point of like follow up calls, literally put in your note. I put a note to myself of like, there's like a lifestyle, like whatever problem in my problem list under like therapy, medications, workup, whatever.

Um, and I'll put like the thing we, that we talked about probably impacts their mood the most and be like, they said they were gonna go to Zumba once before they next see me ask about Zumba and mm-hmm. Just remembering and asking. Um, and they then they know that you actually do remember and ask, and not in a like, did you do this or else, but just to like, mm-hmm.

Someone else is invested in you and cares about helping you build a life that's meaningful to you despite, and [01:03:00] with and alongside the depression can be important. Yeah. That's my, my thought. This is my like soapbox as outpatient chief this year is like, just ask them about it the next time. Like, remember.

Preston: Yeah, I'm, so I'm going to like a full outpatient panel starting July, so, um, I'll be excited to employ some of these. I did have a question, um, about safety planning. 

Mm-hmm. 

So how do you incorporate that into like, the outpatient interaction? 

Margaret: Yeah, so I think that with safety planning, this is like the longer the like schematic of it.

First of all, I have a dot phrase that is like the safety plan that I think if you google safety planning, it's like the one, 

Preston: the 

Margaret: safety plan. Yeah. So I don't use that as much anymore. Um, but with safety planning, so once you kind of understand the story, the story part helps us figure out what are the most possibly predictive changes that we can make that can help with stabilization.

So let's say someone's pain is [01:04:00] worse, maybe that means part of like, so thinking about reducing where we can, any kind of emotion distress doing those, that that's one bucket. The second bucket, like is after you assess where they're at with how do they have access to firearms? Do they have these things that they've prepared?

Are they in like living alone? Are they having contact with people? Is asking the question, okay, if these thoughts came up again, like if you had the urge to go to Walgreens and get a medication you could overdose on again, what do you think would happen next? And, and how do we make a cope ahead plan?

[music]: Mm-hmm. Like how 

Margaret: likely do you feel like it is that you would go get it? And these are uncertain questions to ask, but they're kind of all we have. And then you don't say promise. 'cause there is pressure on the patient to like kind of perform and say, no doc. Or like, I wouldn't do it, whatever, but I would never, but using the calm, relative, [01:05:00] calm state they're in now to help them with this like elevated crisis state that they'll probably go back into.

To say, who would you call? Can we write this down? And I will write this down in the notes so they have it. Mm-hmm. Like, okay, you, you, you could call your, your friend and you don't like, they're like, I don't wanna talk to them about it. Can you call them and just say, I've been having a hard time. See how much they're willing to reach out.

That's also part of the risk assessment. 

Preston: Yeah. 

One thing that I've found, and maybe this is like me learning how to deal with these type two chaotic systems, is that when I introduce it as a safety plan, there are a lot of patients, there's like a certain demographic of patients that will have a lot of resistance to even like the mere suggestion of a safety plan.

Mm-hmm. But then when you kind of put a veneer or like relabel all the different, the same pillars mm-hmm. Of that plan, all of a sudden it's like a lot more better accepted or, or tolerated. 

Margaret: I mean, I think, so the disliking the safety plan makes sense. Like it's become a thing that we have to do for [01:06:00] billing.

So they're like, yeah, dad, da da. It 

Preston: sounds trite. Yeah. Yeah. 

Margaret: And it can be done tritely very easily. Just being like, okay, what are three things? I mean, we've all had the, maybe not all, but we've all had the experience of being like, this person's discharging in 10 minutes. They have to have a safety plan in their, in their chart.

Go do it. And being like, who are three people you live for? Like, that safety plan sucks. I would be tried about that shit too. 

Preston: Were there, like, I told you I'm not suicidal, and you're like, but if you were right, right? They're like, I've never been suicidal. I'm like, but if you at some point in your life became 

Margaret: right, and they're like, yeah, I guess not.

Like, what? What do you want me to say? So I often word it as an outpatient, but I think I would do this inpatient too. Now, at this point, I will word it not as a, I'll say we're gonna do a safety plan, but what I really mean is A, making a plan for you to be more supported and less alone in this for now in the next couple weeks.

And so we can use our brains right now together to [01:07:00] help you know what to do if this feeling kind of elevates again. 

Preston: So maybe try that. I might be too vague with it, but I, what I found has been helpful is I, I mean, these are like people, patients with antisocial traits and substance use in like South Texas.

I like how you Vague. Vague. They didn't like 

Margaret: what I said. So there's resistance and they have anti trait. 

Preston: Yeah. That's my counter. No, but like, I, I be like, like this, this is how a conversation will often go. So would you be interested in making a safety plan? You know, I'm, I'm not fucking safe. If you put me back out in the, like, in the streets, I'm just gonna kill myself again.

Mm-hmm. Or I'm just gonna try to kill myself again. I'll be right back here. Is that what you want? Yeah. I'm like, cool, cool, cool, cool, cool, cool. Nice, nice. 

Yeah. 

So no, no to the safety plan. But, but then what I found instead is if very, like, almost like disarming, just kind of like hands in pockets, casual, poach.

I'd be like, I'm just Turing. You like, what? You [01:08:00] out your shoe while you walk down? Like, yeah. I'm like on my, on my like pigeon toed. And I'm just like, so man, what's, what's been stressing you out lately? Oh, you know, you, you get stressed when you don't sleep very well. And, and so instead of like ident, instead of saying, what are warning signs that I might be suicidal, I'm like, what are the things that Right.

Make things tense for you. And then instead of falling up by being like, what are your coping skills? Have you tried deep breathing? You know, while you're, you're out in like hundred degrees, have a, like, underneath the overpass. I'm like, you know, you feel kind of dumb about that. But then, but then you can say like, how do you de-stress?

Like, I've found that instead of saying like, what are your coping skills, how do you de-stress as kind of like a good lateral exchange. Yeah. And for, and like that has like. Nearly a hundred percent success with me. Everyone likes to talk about how they de-stress. Yeah. No one likes to talk about how they cope.

Right. And you're like, okay, you're, you're right. I do. That's way different 

Margaret: in the children's hospital. They, like, we have to do, it's like not even a safety plan. It's like a a, you've maybe seen something like, it's like a thermometer and it's like an emotional intensity chart and then like [01:09:00] things associated with those like people events and then things that make it go from like an eight to a five on the intensity.

So I'll often speak to it that way of like, what turns the volume down. Like if you are feeling really, really, like lonely and that is the emotion associated with when you start having more suicidal thoughts, like what is something that alleviates it 10% or just turns the volume down and makes it less all consuming.

Um. 

Preston: Mm-hmm. 

Margaret: Or what is the thing that makes it go up? I don't know. I feel like I haven't been an inpatient for a while and the conversation has a different tenor when you're an outpatient because it's like not as adversarial because you're not in a locked unit. 

Preston: Yeah. And, and I'm not seen as like the prison warden while I'm also trying to like navigate like the, the eggshells of the conversation 

Margaret: Yeah.

Preston: To, to get some hopefully something like meaningful out of them. 

Margaret: Yeah. I'll say something for you to look forward to is I feel like all the safety conversations I've had and out, most of the safety conversations I've had in outpatient have been like, [01:10:00] you also just know people. I don't know. I feel like you, I know my longitudinal patients better.

They've been mostly like meaningful and, and there's not that feeling. I think I had more of it when I was inpatient of like that the one, the kind of conversation you're talking about that's like, what is this, what are we doing? Like you've been here for five days, now you're leaving. And I'm just like, what are three things, hobbies you like to do that will make you less suicidal?

Like, dude, that sucks. Um, and I also think there's something in residency about like, you can't, they're discharging, you're not gonna see them again. There's that part of it. But it's like when you're an outpatient. You know, you staff with attendings, but they are your patients and like you truly are the one who knows them the best in the clinical team.

And so I think there's also something that is creative and more personalizable when you're the like, main person helping them come up with it versus just being like a resident in an inpatient unit where they were there for four days, who's like, has to go to this 

Preston: four week. Yeah. Like, like to them I'm just a rotating badge.[01:11:00] 

Margaret: And that's what you are to me too. 

Preston: It's, it's fair. It it um, and sometimes it's nice, it's like Groundhogs Day a little bit like you go to talk to, to a patient and they've completely forgotten you from the day before. This ever does happen to you when you're inpatient? I feel this happens to me on consults all the time, and they'll be like, yeah, the psychiatrist before was asking him all these invasive, annoying questions, but you're cool.

And I'm like, that was me yesterday. I'm just literally in a different outfit. 

Margaret: They're like, well, all right, Dr. Mr. Like tomorrow, 

Preston: you know? We'll, we'll kind of see. I'll be like, which interview style resonate the best with? Oh, that guy. 

Margaret: You're like, you're like, I do come in some days wearing wigs, like, just don't recognize me.

It's so weird. 

Preston: Just take off the mustache and the glasses. They won't know what hit him. 

Margaret: I just thought, okay, I'll tell you this later. Um, 

Preston: I think that rapport is necessary for these kinds of conversations. Yeah, and I think we try to do in a lot of ways, like a bastardized version of like, of a procedure that needs a lot of [01:12:00] mutual trust and rapport.

Margaret: I think it does. I also think there are like people who are really good at the inpatient setting that. They understand the frames so well that they know how to build rapport within that frame. I feel like this after moonlighting for the last couple years, that like certainly I prefer not weekend rounding, which is what our moonlighting is for psychiatry here because I meet like a bajillion people for like five to 10 minutes each and mm-hmm.

But I will say it's gotten so much easier to feel connected to people in that weird setting when I learned how to like elicit, like how do I connect to people and also make them not confused about what we're doing and not like there is a lot that's limited to inpatient into that. But I also just find that there are people who are like on CL who are so good at like forming a temporary but a bond with a patient that they're only gonna meet a couple times in like, you know, three or four times in like seven days.

I dunno, I think there's something to be said to that. I'm not that person, but I've [01:13:00] like seen people who are so good at that specific form of connecting in that setting. 

Preston: Yeah, I, I've seen some people that are, they're excellent at it too. I think I'll, I'll have times in certain patients where I feel like I kind of hit it, and then a lot of times it's just, it's, it's frustrating and it's counterintuitive.

Yeah. 

Some, sometimes the best thing to do is just you don't try to overexplain situations, but you just, like, you use a lot of reflections. Reflections kind of, you kind of, you, you act like surprised and share emotions with them really openly and then just kind of like, think out loud, which are, which are like really hard things to do in inpatient settings.

Yeah. But, but then are ultimately like the most effective for like building these like, tight quick alliances with patients. 

Margaret: Yeah. No, I totally agree. Okay. Are you ready? Let's, we'll just do one case example. Okay. Because we don't, I don't think we have the time to do two. Um, so I'm going to give you a vignette.

We're gonna do an outpatient one because that's what we've [01:14:00] been talking about. And also because I think, again, the outpatient setting. It's hard because you're, I feel like it's hard for three reasons, for a lot of people, outpatient is the first time when like you're, again, you know, this patient the best over time and like maybe your attending switched da, da da.

So they feel like, like, this is my patient. They feel like that inpatient sometimes, but like outpatient gets even more so too. Mm-hmm. You're not in the hospital. Um, so if they don't want to go to the hospital, it is a time where you have to make, you're not, it's hard to section people or have restraints happen, but it's like, are you gonna send someone to their house?

Are you gonna like force, there's a lot more force that in some ways you have to use an outpatient if things get to the level of that acuity. Um, continuity. Um, I don't remember the third reason I had in my mind. Maybe it never was there, but, so are you ready? 

Preston: Yes. 

Margaret: Okay. You'll be graded on this. I'll be sending it into the ports.

Um, okay, so you are a third year. [01:15:00] It's the fall in Texas. I don't really know what the fall in Texas looks like. Um. You have just finished your mindfulness practice and you're sitting in your office and you are meeting with a patient who you've known for six months. You've met with them six times. They have a history of depression.

They're a 28-year-old male. What? You're they're, they're 

28-year-old. It's me. It's you. No, it's not. 

Preston: I'm you and you, I'm 

Margaret: you we're one. Um, 

it's a 24-year-old male. Um. Who has a history of depression that has been stable during your work together? Um, he's had one suicide attempt in the past when he was 17 after a breakup.

Um, he's been stable with you on 40 of Prozac with minimal side effects. Um, he does struggle a little bit with alcohol, um, mostly with a binge drinking pattern that started in college and has kind of continued into young [01:16:00] adulthood, but has not had any complicated withdrawals or anything like that. Um, he is living in Texas and does have a gun and 'cause he likes to go hunting and also has a hand gun.

My not knowledge of gun is showing guns are showing 

Preston: what is gun. He has a big gun and a small gun. He has a 

Margaret: big gun and a small gun. Um, and he's coming into your office and he sits down and looks at you and says, things have been really hard lately and I'm feeling like I felt when I was 17. And so I, what we're gonna do for the next few minutes, and I have a timer, um, is I want you to interact with me like this is the patient and then we'll, and I want you to, um, uh, let's say you already did like all the, like other, there's nothing else going on psychiatrically.

I don't suddenly have psychosis. There's no other substance or anything like that. And you're, you've covered all of this information in the first 20 minutes of the VI [01:17:00] visit. Now you have five minutes for you to go at your attending where you need to really drill in on what, I mean when I said I feel like the time that I was 17 and suicidal.

Preston: Yeah. Okay. So, so what you're getting is like this acute safety assessment? Yeah. Gotcha. So around the time when you were 17, tell me about the thoughts that you were having. 

Margaret: I mean, I feel like I like was already depressed in high school and then my like girlfriend broke up with me. And I, I mean, I don't even remember.

I, I don't even feel like I had like, a lot of thoughts. Then it was just like mm-hmm. Things just felt so fucking bad that I was like, I just can't feel this way anymore. And that's when the 

Preston: mm-hmm. 

Margaret: Overdose attempt happened. Gotcha. 

Preston: So when a lot of people are experiencing distress or, or thoughts that they, that they can't handle, they have this desire to just escape, not not 

just life, but like the world.

Do you [01:18:00] find yourself having those thoughts? Like, I wanna say no, but 

Margaret: I feel like that's why I'm like scared. 'cause I feel like 

Preston: mm-hmm. 

Margaret: I don't want to want to die. But also if you said mm-hmm. Like, okay, you can go to sleep and choose that you're gonna die or not, and like, it wouldn't hurt anyone. I kind of feel like I would choose that.

Mm-hmm. 

Preston: So a, a part of you says. 

It sounds nice to just go to sleep and not wake up. And a part of you is scared that you may actually entertain this thought 

Margaret: Yeah. And 

Preston: move towards harming yourself. 

Margaret: Yeah. Because it feels familiar to that time when I actually did. 

Preston: Mm-hmm. Have there been moments during this episode where your mind's wandered and, and thought how you might actually do it 

or, or maybe felt comforted by the thought of doing it?

Margaret: I mean, I, I have a, you, like we talked about how I go hunting with my, like [01:19:00] brothers. Mm-hmm. Um, I have a gun, it's like locked and not loaded. 

Preston: Mm-hmm. Because 

Margaret: my girlfriend is like, don't just, I just doesn't trust guns. Um, so like I know I have that and it has crossed my mind that that's what I could use and then that scares the shit out of me again.

Um, what was the other thing you asked? 

Preston: If there was a time where the, the thought came up and it 

doesn't scare you, or has it scared you every time? 

Margaret: I think the idea of like actually doing that scares me just 'cause of how many people it would impact. But there's also, there's been a moment, there was a moment when I was driving the other day and I thought I could just drive off the road and make it look like an accident.

Mm-hmm. And that kind of stayed in my mind for like a moment. I didn't do anything with it. Mm-hmm. But it was like not, [01:20:00] it was, it kind of felt like relief 

Preston: that time. It didn't, it didn't go. 

Margaret: No. And it felt like a, it did feel kind of like a relief for a second. Like, oh, I could just be done. 

Preston: What do you think pushed your mind to that?

I mean, I think like, 

Margaret: I don't know dude, like I just, I've. I've been out of college for like a year and a half. I feel like all my friends are like settling into their life in like different places. Mm-hmm. And like, I have my like girlfriend, but like, honestly, it feels like it's not working. And I, I don't know if that's my depression or if that's us.

Preston: Mm-hmm. 

Margaret: And I just feel like I, like don't like my job very much and like I've known these things, but it just feels like it's not getting better and I don't know if it ever will feel. Mm-hmm. Like we're, my college year is just my golden kind of age and like, that's the best time in my life and now I'm just gonna feel like this forever.

Mm-hmm. I think that's just been like, [01:21:00] worsening. And as it gets like further out, like I just feel a lot of pressure of, like, I do, I break up with my girlfriend or propose to her, do I like stay in this job? Mm-hmm. Do I move? Like, and that's just been increasing over the last like six months. 

Preston: Mm-hmm. Those are a lot of high pressure 

things.

All, all. Kind of intersecting at once. So no wonder you're feeling stressed about it. And me stress is probably an understatement compared to what you're dealing with every day. Yeah. It just doesn't feel like things are gonna get better. Mm-hmm. So as far as today goes, I wish I could, 

you know, wave a magic wand and give you perfect clarity about what to do with your girlfriend and find you a new job.

Fortunately, I'm, I'm all out of magic wands, but there are some other things that we can maybe change to make life a little bit better [01:22:00] right now. So I know we've been stable on Prozac for a while and it, it sounds like it is helping you, but you also are at a sub maximal dose. So one thing we could consider is going up.

Mm-hmm. Not because your depression's getting worse. It could just speak from a response to your environment. I think we can find out, um. 

I wanna 

follow up with you again in two weeks so we can kind of keep a closer eye on how these medicines are doing. As far as kind of these thoughts that are dangerous to you, I, I want to talk more about these 

firearms at home.

We know that you have this history of a suicide attempt and, and all the factors that have led up to this are kind of happening again. 

What are your thoughts about, um, 

finding someone to, to give the firearms to, or to store them somewhere else where you're not tempted to them or don't have to think about them anymore?

Yeah, I guess I could, 

Margaret: it just makes me [01:23:00] nervous 'cause like it's, it's hard enough like telling you this stuff, but I, 

Preston: mm-hmm. 

Margaret: Even like telling my girlfriend makes me hesitate, but I, I think I can, and I also think, I think you're right, and I, and I should have her take them to like her place or like take, I don't know, take them to her like.

Parents' place? 

Preston: Yeah. If not your girlfriend, who else can you reach out to for support?

Hmm. I think my sister, like, 

Margaret: we don't always see eye to eye sometimes 'cause she's like too emotional for me, but 

Preston: mm-hmm. 

Margaret: She, I think, would be able to talk to me about this stuff and also just like, be there for 

Preston: me if things feel bad. Mm-hmm. She lives like an hour away. Okay. So your girlfriend and your sister, is there anyone else in your life?

Margaret: I, I [01:24:00] haven't talked to him in like a year and like, I've been really bad about, like, we've been bad about like texting and catching up, but my like best friend from college, like had mm-hmm. He didn't have depress, he had like anxiety and we talked about mental health stuff sometimes and he was always like really good at that.

I, I could text him at the very least, or like text him now or soon just to like reconnect. And I honestly, I should do that anyway. Like, I think the depression has made me less social and like maybe reconnecting that line. I think I would, if I was like, no, if those other two didn't answer, I would still, even though it might be kind of awkward, like I would be able to call him and talk to him and if I was feeling really low again.

Mm-hmm. 

Preston: I think it's a wise and a brave place to start. How about, um, you plan to call him or just reach out? Yeah, let's, and then I'll 

ask about that at our next appointment. 

Margaret: Hi. 

Preston: Is that time? Yeah. 

Okay, 

Margaret: dude. Good job. I thought you handled that great. I feel like you don't 

Preston: see me in clinical scenarios a lot, so [01:25:00] 

Margaret: I don't see you in clinical scenarios.

Preston: Yeah, yeah. Well, you don't, you don't work with me. You only get to see Podcast idiot press 

Margaret: listeners, 

Preston: right? I actually, yeah, I'm actually okay. And it'll be sometimes I don't think you're not 

Margaret: okay at your job. I like what do you think? This is like a rehab project for me. For you. 

Preston: Yeah. You're you're right. 

Margaret: I like talked to you on the phone one time and I was like, this guy needs my 

help via a podcast.

And That's right. No. How did that feel? How'd it go for you, for your experience? Um, 

Preston: I think it felt, it honestly like, felt very similar to like, conversations I'll have with patients that have like, I have a good relationship with and they have like kind of insight into their, their concerns. Um, so kind of like one thing that like I did, which was like, I.

What I talked about kinda going back and forth on, which is I was walking through the safety plan with you, but trying to make it feel just like an open-ended conversation. 

Right. 

And so I'm identifying [01:26:00] those same pillars 

Yeah. 

Of like your, your dissatisfaction with your job, your relationship trait, these other things are kind of what like leads you to these suicidal thoughts.

Mm-hmm. And then, um, kind of we identified that their passive suicidal ideation sometimes flirting with active. Mm-hmm. And so, so for listeners aren't familiar, passive is kind of ego dystonic thoughts about harming yourself. And, and sometimes it's more morbid ideation of like, I wish I could go to sleep and not wake up.

But then active suicide ideation is where it becomes ego syntonic, where it's like in line with your beliefs and you're like, okay with the thought and wanna act on them. 

Margaret: I think there's also like the level of time like you had asked with like the car driving, like, okay, so that stayed with you and you were kind of entertaining it more versus like an intrusive, like I think about like patients with OCD and depression mm-hmm.

Who can have like both intrusive thoughts that like. Flip by, um, yeah. Thoughts that come in from depression and are like merging into ego syntonic and feeling like a relief and not just kind of an image that [01:27:00] passed by. 

Preston: I mean, I think he responded really well to like my reflections. So I, I love to use like nuggets from motivational interviewing with patients as soon as I identify any kind of tension.

Mm-hmm. And like suicide is a great example of where there is tension in someone because you have these thoughts about killing yourself, but you're clearly alive. So, so, so inside of you is different part is a lot of stuff that's pulling. Yeah. Yeah. So, so then just being reflected, like, a party feels this way and a party you feels that way.

Yeah. Um, yeah. I think it could be like eyeopening to people who have trouble kind of engaging with that dialectic. 

Margaret: Yes. But that 

Preston: also it, it shows an understanding of them. 

Margaret: I mean, I think you did a great job of keeping it as a conversation and a narrative while also getting the kind of. Hitting the things, even when it was hard, even when I kind of purposely dropped the, like, it just feels like things are hard and are never gonna get better, right?

Like, the reality of our clinical time is that while that sentiment really pulls for empathy and to have you slow down and not have to ask, like, okay, well I need to ask you these questions [01:28:00] about are you gonna mm-hmm. You know, do you have guns like 

that? Mm-hmm. 

You were able to keep going. I think that is though also a tension point in these kind of interactions when someone's really struggling is, will you keep the patient if you push for more data or will they feel unheard and start to disengage from you?

Um, mm-hmm. But I thought you did that well. I think, um, you were good at like, eliciting from me more of the engagement with the safety plan to make it personal and not just like, I'm gonna list three things that I feel no salience to. Um, yes. 

Preston: Yeah. No, I, no, I, I agree with that. Like, I'm thinking about all like the.

The shit safety plans I've done so far in residency and, and like, how hard it's to do them effectively and, and personally. 

Margaret: Yeah. Yeah. I think the one part maybe where it was a, not a misstep, but like maybe would've made a different choice on like the wording of like, I don't have any [01:29:00] magic wands, but maybe would've had a little more empathy.

It, it can come across as kind of like, okay, well I don't have anything that can do that, but this, so, but I hear you on, that's, that's, that's good feedback. Thats a minor gripe. 

Preston: So the reason why I use that like line sometimes is it's, I stole from palliative. Mm-hmm. They do this like, kinda like the wish and worry statements.

Yeah. I love 

Margaret: the wish and worry 

Preston: and so, so that's kind of what I'm doing. I, I'm, I'm wishing with my magic wand and then I'm worrying mm-hmm. About this. So what I try to say is like. I support you and this is what I wish I could do for you. And then also I need to ground us in reality and what we can, what is actionable now.

Right. And sometimes I think maybe I try to kind of rush that bridge. Yeah. So, so I think, yeah, you're right. It comes across as like, I don't have, I wish I had a magic wand, but also I can't do shit. Yeah. You have to do this other thing. 

Margaret: Well, so maybe, maybe like, when it's not rushed, I'm not putting you on the spot.

I, I think one of the ways to do it is to be like, slow down for a moment with the empathy part and kind of say [01:30:00] it is so difficult that like, whatever in your voice, like, it's so difficult that this is here and we have to talk about all these small things that hopefully add up to helping you. And I, I so wish that we could just change it right away.

'cause you're in so much pain right now. 

Preston: Yeah. 

Margaret: And then say, and then moving, um. 

Preston: It's kinda sitting with, that's a 

Margaret: stylistic comment. This is also finishing the psycho analytic fellowship. This is what we do every Thursday night for four hours and be like, you said this and I wonder what you were actually internally feeling and how, and then they seem to do this.

So you're getting some of that. I'm sorry, but it's been so helpful for me. 

Preston: Yeah. Well, it's helpful for me. S and this is, I know we're wrapping up. This is a question I had that, and this could be a whole nother episode, but I feel like the finger. I've been trying to use, well, like I'm, I call it like intentional unprofessionalism or like professional unprofessionalism, which is where like you reflect the patient's language and like openly like cuss with them or things like that.

Yeah. As a way to kinda like validate their experience. Mm-hmm. So like [01:31:00] for example, when someone's like, I've been hearing all these fucking voices everywhere, and I'm like, that fucking sucks. Yeah. And they're like, it does. Yeah. You know, like there are a lot of people that kind of use these like political detached, like robotic language around them.

And then when you're the first person who can like, reflect their language back to them, even though it's like wouldn't be considered professional, a lot of clinical environments to be cussing like that. Mm-hmm. They see it as very humanizing. Yeah. And, and it kind of is to be like, Hey, I'm gonna cut through all this BS and be like, acknowledge that.

Like sometimes the best word for a situation is like, that's a shit show that's fucked because sometimes it is a shit show. We're losing the battle 

Margaret: of ever having a non explicit episode right now. Yeah. Every episode's rated EE 

Preston: for everyone. We can get into the, maybe the more, uh, half-blood print style versions of, uh, supportive psychotherapy later.

Margaret: What was your question? Just should you do that? 

Preston: No. Yeah, yeah. So my, my question was like, do you have an opinion on that? Like, 

Margaret: I have the [01:32:00] frustrating opinion of it depends, like, 

Preston: yeah. So 

Margaret: for example, let's say I have someone in my clinic who has been a population of people that has been underserved by healthcare, discriminated against by healthcare, been literally mistreated by clinicians in the past, had someone break a boundary.

All of these things, right? Or there's, let's say I have a female patient who's very, very, like blocked up and anxious and can't show any anger or assertiveness or be imperfect with her. I might on purpose cuss and like not do my makeup that day that we have therapy together, two. Reflect that that is okay in this space and that that kind of interesting, that edge is all right.

I'm not that thoughtful all the time with people, but there, there is that level of like, do I bring this in? I think there's also just something to be said about like, your personality will come through and it's part of how you work with people. And obviously I cuss you cus I do cuss a little on TikTok.[01:33:00] 

What's your favorite fuck? What's your favorite 

Preston: Sade? 

Margaret: Um, so I don't ever try to fully be a blank slate, but I think that this kind of, the knobs you turn on which parts are important for people is not inauthentic. It's just like, what's important here? Because all of us have these like thousand facets of us and as a therapist, I think choosing Yeah, what 

Preston: levers of, of myself kind of used to be most effective here.

Whereas 

Margaret: if there's someone who's like. Also very professional and seems bought, like it could be a very similar patient, but they're someone who seems like they really value professionalism and or they are someone who doesn't believe in, like, cursing themselves. So it makes them uncomfortable. Or if that's what I'm sort of picking up, even if it's like they actually ideally someday wanna get to the point where they're more comfortable with anger edge or imperfection, but they're not there yet.

Mm-hmm. Then I won't do it in that session. 

Preston: Yeah. They won't try to shatter the decorum. 

Margaret: Right. Because it's like not, it's in the, in psychoanalysis to say, it's like it's not in the neighborhood of the knowing. Like it's not [01:34:00] gonna gonna do that. Right. Um, so yeah. Interesting. I think that's my view on, or it's like they have someone who like, has been too personal and like not crossed boundaries in like a crime way, but like someone who like would tell them things about their lives as a therapist or crossed lines.

That way I will be purposely more professional because they've experienced those infractions. Yeah. And maybe that'll relax over time, but like Yeah, 

Preston: no, that, that makes sense. Like I, I have patients who, they've had therapists before them where they were like, literally would tell them what to do. Like, you are going to do this.

Yeah. And like, you are going to make a resume and I'll review it at the next session. And then with those patients, I'll be like, very deferential with them. And I'm just like, you know, I won't even, I won't give you any advice. This is all, this is all in your ballpark. Yeah. I think that's a good way to wrap episode answers.

It could be a whole episode Before we continue, just psycho answers continue to ramble into, into the sunset. 

Margaret: Yeah. Well, oops, we're having like a two hour episode. 

Preston: [01:35:00] Yeah. Ysi. So Whoopsies. 

Margaret: Sorry guys. It's a treat even a little extra. The treat today. 

Preston: Yeah. Hopefully your commute's a little bit longer today. 

Margaret: So we have, I can say the username this time because it's psychiatry intern and they left this review on Apple Podcast because reviews help us.

Even the ones that are telling me I should shut up. Um, but 

that this one didn't do. That's what if I start the one that was like, you should stop laughing. Cut it off. I'm like, girl, I can't. I'm sorry. 

Um, okay. The real one though, as an incoming psychiatry resident, how to be patient has been very thought provoking.

The host psych residents themselves bring a refreshing mix of clinical insight, self-awareness, and humor to each episode. I love how they weave pop culture into deeper conversations about identity growth and what it really means to care for others and ourselves, their honesty and relatability. Make the podcast be like a conversation with trusted mentors and friends.

I love it. Three exclamation points. Thank you. Psychiatry intern. We do read these. 

Preston: We, I'm gonna use, that person represents all psychiatry interns now. 

Margaret: Mm-hmm. They all love us. 

Preston: We are, [01:36:00] we're ubiquitously love. 

Margaret: It's okay. The hate is so good for developing a stronger sense of self. I know. She says to herself in the corner, 

Preston: I just want you to know if you leave a hate comment, it's probably gonna be screenshotted by Margaret and sent to me.

Margaret: And say, 

Preston: and then, and then store to my favorites folder. 

Margaret: Why are you saving them to your favorite? You're like, I save every photo you sent me to my favorite. 

Preston: Yeah. So thank you as always for listening, for all the kind comments, for all the hateful comments. They are all going in our portfolios. If you wanna let us know how the show was and actually, and have, um, pointed feedback, we also want to hear it.

Yeah. We, we may, that's or may not laugh more or less, but especially things around like the topics you want to hear or questions that you want to ask or want us to ask. 

Mm-hmm. 

Um, they can be very helpful. So on Instagram and TikTok at Human Content Pods, or you can message us at how to be patient. We are on Instagram now on Instagram.

Margaret: Not really TikTok. It's, 

Preston: it's like our, it's like our own little Neo pet. It has like 2000 followers now. Yes. And we, so both [01:37:00] Margaret and I monitor that account. So with no schedule, we DM people and all. It's, it's just like in the evening. Doom scrolling, but we'll come across it. Don't worry. We will come across it if you wanna find, and 

Margaret: then they'll be like, have you ever messaged someone back when they DM us?

And then like, I bowl people. Be like, this is Margaret, isn't it? Because like I can tell by, have you talk. 

Preston: Um, yeah girl, it is. If you wanna see stuff from just Margaret, she's on bad art every day on Instagram and TikTok. And if you want find stuff from just me, it's, I'm at Prerow on, um, TikTok and it's Prerow on Instagram.

YouTube the full, how are you? Lemonade of the podcast. Sorry. I mean, not, I'm, I'm on red note, but not lemonade. You 

Margaret: stayed there. 

Preston: Oh, wait. Lemonade. Lemonade. Like lemonade? No, no, but it's like lemonade. Yeah. It's like the punt. It's Are they not marking this hard 

Margaret: at you? They're trying to get me in all the aesthetic Pinterest girlies on there.

No, they 

Preston: got me with, they got me through red, red note. I'm staying there. Shout out to psychiatry intern for leading that wonderful feedback and everyone else who's believing feedback, we, we [01:38:00] really cherish it. Thanks again for listening. We're your hosts, Preston Roche and Margaret Duncan. Our executive producers are me, Preston, Roche, Margaret Duncan, will Flannery, Kristin Flannery, Aaron Corny, Rob Goldman and Shanti Brook, our editor and engineers.

Jason Portizo. Our music is Bio Benz V. To learn more about our program, disclaimer at Got our babysitter 

Margaret: producer. Is Tessa our babysitter tonight? Thank, 

Preston: thank, thank you Tessa. To learn more about our submission verification, licensing terms, our HIPAA release terms, go to How to be patient pod.com or reach out to us at how to be patient@humancontent.com with any questions or concerns.

How to be patient is a human content production.

Thank you for watching. If you wanna see more of us or [01:39:00] if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the background.