Thank you for showing up so early on a Wednesday morning and I'd like to thank my co-presenters for showing up so early. Unfortunately one of us was not able to make it, Dr. Nidris unfortunately was not able to get time away from work and I think that is actually emblematic of what we're talking about today. We're going to be talking about how our systems of care are struggling and one might even say we don't even have a system of care, we have multiple pieces but not so good coordination between those pieces. So we're going to be addressing that from three different perspectives. From outpatient with Dr. Chinoy, I am going to actually present Dr. Nidris' presentation and obviously it will not be as good as if he were presenting his own presentation. I hope nothing is lost in translation and then Dr. Parikh will be presenting regarding inpatient hospitalization and in addition to talking about the problems, the shortcomings that we face, we're going to be showing a little bit of some resources. So there will be a recurring slide between each presentation that I'd like you to take a photo of. This slide has both a workforce map that shows areas of shortage of child and adolescent psychiatrists throughout the country and it also has three QR codes. I hope you know what a QR code is. You can either use your smartphone camera to view the QR code and it will pull up a website. Within each website there are specific resources. So the first is the American Psychiatric Association's advocacy resources. There are many. You could get lost into a rabbit's warren of wonderful information. The next is the American Association of Child and Adolescent Psychiatry's advocacy site, which has a huge amount of information and all of it is accessible to you. And the third is actually very important. Raise your hand if you've heard of the WIT ruling. No? All right. So the WIT ruling was a lawsuit that occurred against UnitedHealth about three to four years ago. And the decision in the WIT ruling was that insurers were not allowed to make up their own medical criteria for what level of care a patient should have. They should instead rely on standards. And those standards should come from providers, not insurers, and that it should be transparent. And so the WIT ruling actually mandated that insurers would use CASI or EXI, which are both ACAP screening tools for medical necessity to determine where a child would best be treated. So unfortunately the WIT ruling was overturned on appeal, but the Kennedy Forum and the State of California enacted a law that encoded the WIT ruling into the State of California's law. So the very last QR code that you will be seeing is the exact law. You can take it to your state legislature and you can try to get it enacted into your state. Because remember, health care is determined state by state, and so the law has to go state by state, too, for insurers. So these are some tools to empower you. If you don't have the bandwidth for advocacy, please share these resources with someone who is excited, has time, wants to explore, but doesn't know where to turn. All right. So with that introduction, I'm going to introduce Dr. Shannoy to talk about the outpatient experience. Hello, everybody, and good morning. First of all, thank you for being here. I was one of those that would wonder if I really have to go on a Wednesday morning, but being on this side as an early career psychiatrist, you all have inspired me to continue to work hard and continue to present and advocate. So thank you. So my topic, socialization in children and adolescents from an outpatient perspective, especially during the pandemic. Financial disclosures and conflicts of interest, yes, I do have student loans. Sometimes I'm very internally conflicted. Meditation helps. Not on medication yet. CBT, not CBD. Okay. So I have always tried to look at any problem with our sentinel questions that our Greek philosopher Aristotle, you know, came up with, the five Ws and how. It helps problem solve, and it gives you an all-around perspective. So who am I? I'm an early career psychiatrist. I'm a child and adolescent psychiatrist. I trained in Bangalore in India and got here. I'm an international medical graduate. Did my residency and fellowship in Springfield, Illinois. Once I finished, I spent some extra time in Washington, D.C. with ACAP trying to advocate. Therefore I graduated a little off cycle, and I started my attending life at the beginning of the pandemic. So imagine doing that. Imagine doing that. I'm pretty sure some of you in the crowd know that. So what are we going to talk about is this unfortunate topic of pediatric suicidal ideation. What time frame I'm going to discuss is from just before the pandemic till now. Where I'll talk about two different settings. The first one is at a federally qualified health center in the outskirts of Chicago. One hour, one and a half hours depending on traffic from downtown Chicago. The second one is I'm currently practicing in downtown Chicago in a large urban setting on the river itself. So it's in the heart of downtown. So those are the two locations I'll be discussing. Why is this important? See, when I was studying for USMLE, the term suicidal ideation, the poster child for suicidal ideation is an old white male, divorced or separated, has access to firearms. But what if I told you that it's changing? Now it's a young Hispanic or an African American kid who should be enjoying life. But that is the population demographic that has the highest suicide rates these days. So that's why I want to talk about this. The next is how? The last one. So I hope at the end of this I'll give you some questions as to how can we make this better. And my fellow presenters will help, you know, fit the pieces together. So wipe check. I learn new language from the kids that come to me, right? The kids that come to me, they teach me. They are like a live Reddit stream. They keep me updated better than any CMEs, okay? So wipe check. How many residents in the crowd? One, two. Thank you, thank you. How many fellows in the crowd? Thank you. How many med students in the crowd? Cool, thank you. Thank you. How many early career psychiatrists within seven years of practice? Thank you. You are the crowd that I was hoping to convince and you guys know my struggle. And how many after seven years of practice? Thank you so much. Next. That's exactly what I was going to ask. I didn't want to have polls and have you do things so this is better. Old school is the best school, right? Okay. What I'll do is I'll present some cases. I'll try to go as fast as possible. And from there on, at the end of every case, you'll have a question. Like, I've given you that situation. And I will tell you if you are at an FQHC or if you are at the urban setting. And what would you do if you were the attending physician? Would you admit this patient? Would you send him home? Would you continue to treat him on an outpatient basis? Stuff like that, okay? So think of it like this. So five cases. I'll present some important details about these cases and I'll ask you what would you do. Okay? The first one. Again, I didn't want to crowd the slides. Old school, right? So you can look at me. I'll tell you. So the first case is a 13-year-old Hispanic girl that I saw at the FQHC setting. She comes in with her dad. Dad says, I mean, we have an interpreter who is helping me understand. The dad says she's been saying she wants to kill herself. And, you know, I'm trying to get to know other things. I'm not jumping in directly to, like, why are you suicidal? Of course, I'm not going to do that with a kid, right? With anybody, that is. But I ask her. And she's quiet and she's answering my questions about, like, where she goes and all that. I'm trying to get to know the picture. She says, mom. Okay? And that point, she keeps, like, done. No more answers. And she starts looking at the female interpreter, the Spanish translator, in the room. And that's all. She's looking like this, doesn't answer questions and all that. And I'm thinking, oh, this kid, something's happened. They have already told me she's suicidal. I need to admit, admit, admit. Because, you know, sometimes when you're a resident, you hear the word suicide, you're like, admit, right? And I'm thinking, admit, admit, admit. So I slowly bring up the idea to the father, through the translator, saying, you know, if she's really suicidal and she's not giving me any information, I might have to consider hospital admission. That point, this guy flips. He's like, he stops talking. He's like, oh, no, no, no, she's not suicidal. All good. Right? I'm like, what's going on here? Okay? Turns out, one week before that, there was an executive order, because those days we used to have too many of those. And mom was deported the last week. And since then, the kid is, you know, stressed out. Her mom has been taken away from her. None of the family knows what's going on. Dad is not talking there. So if you go to the hospital, just like an FQHC, he's worried there. What kind of social security number should I give? What ID card will they ask? Will I get deported? Will my kid be sent to the migrant camp? So he's turning around there. Okay? What would you do in this situation? That's my poll question for you. Involuntary inpatient psychiatric hospitalization. You know, fill out the petition, fill out the first certificate, or whatever the state rules are. Send them to the ER and let them deal with it. Call 911. Let them deal with it. Oh, well, start an antidepressant, right? SSRI. Send them home with that. Or do not start a medication, because you don't know what is going on. None of the above. How many for A? One, two. How many for B? Thank you. I love that. No one raised that. Okay. How many for C? How many for D? How many for E? Okay. Two, maybe. And how many for F? Sweet. Thank you. Next. My next concept. Were you trained in telemedicine before COVID? One, two, three. How many? Well, I changed the question. How many of you were not trained in telemedicine before COVID? So many. Right? Okay. How comfortable would you feel if that patient was on a telemedicine and talking to you from a different location with a different, you know, translator using a different Zoom screen? Can you hear me? Do you understand me? Anyway. So next point is... Okay. That was my next point. Go to case scenario two. 12-year-old... After this, I'll be, you know, going faster because you got the layout of how my cases will be presented. So the second one. 12-year-old Caucasian male. Outpatient clinic using telemedicine. This kid was doing well. I would say upper socioeconomic status family. Parents are working. Kid is at home. Online school. Hybrid school. Something's going on all the time. Mom and dad are working from home. From October onwards, like October of 2020 onwards, this guy was slowly becoming depressed and depressed. When he came to me in early 2021, mom and dad are saying that he's been talking about it doesn't matter if I die of COVID. Okay? So they are like... He's saying passive death wishes now. So we wanted to get him checked out. Right? So no history of any prior, you know, psychiatric medication. Psychotropic. Naive. What would you do in this scenario? Passive death wishes. Somewhat suicidal. Mom sometimes says, I don't know if he's suicidal. A. Option A. How many? Option B. C. D. Anyone? Option C. F. Yup. Many people for F. Thank you. Next case scenario three. Nine-year-old Caucasian male. Again, clinical setting is the outpatient clinic. On telemedicine. Again, upper socioeconomic status. Parents are working. Two kids in the house. Nine-year-old and a six-year-old kid. Tantrums have gotten higher with both the six-year-old and the nine-year-old. Because everyone's, you know, life is chaotic. Parents are working from home again. Sometimes hybrid. They go in, come out. What happened was this nine-year-old, during the tantrum, pulled a knife from the kitchen counter. He was holding it. Mom tells me this much story. And then she starts crying. She's like, I cannot, I never thought this is going to happen to my kids. Such a sweet kid. And I'm like, did he say something? Was he trying to hurt himself? I don't know. Was he trying to hurt the baby? Or the six-year-old? Well, he was angry and frustrated because the six-year-old was crying and having a tantrum. That triggered this kid and he was just having a contagion effect-like thing. I don't know if it's suicidal, homicidal, going by our traditional standards of suicidal or homicidal. Here you have a kid with a knife in his hand, mom's crying, very difficult to convince her, takes much more time to get information, my next patient is already checked in on Zoom, friend desk staff and my bosses are like, time up, time up, right, we've all been there, right? Okay, then what would you do, right? Very difficult. Next scenario, case four, Caucasian female, outpatient clinic. This case, I love this, okay, person, this was not telemedicine luckily, dad and let's say her name is Anastasia, okay, Russian immigrant parents, Anastasia is the girl, they come in, dad says she is suicidal. She was just discharged from an eating disorders inpatient residential clinic. She was not suicidal then. She was taken in because for the last few weeks she was not eating, restricting food and all that. So, of course, it looks anorexia, right, so they took her in, when she comes to me, she's on an SSRI and a little bit of lenzepine to increase appetite and she has a dietitian, nutritionist. She comes in and she's not answering questions for me, of course, dad's saying that, you know, she's suicidal. I said, did you try to go back to the PHP program because at least you have some, see, that's my first thought, right, I'm like, and she's like, no, no, no, she says the PHP made her suicidal. Okay, I'm like, I'm trying to get to talk to the daughter, I asked the dad if I can talk and she might answer or something, I asked the dad to leave so she can sit outside, trying to get her to talk. I'm like, Anastasia, that's such a beautiful name, how old are you? Just call me Dylan, okay, just call me Dylan. I am Dylan, I'm not Anastasia. That's when I thought I had a breakthrough. I said, okay, Dylan, thank you. There on, Dylan tells me that it was never about suicidal ideation. What happened is when they give her the SSRI and the antipsychotic and the dietitian and everything, her weight came back up and she started having her menstrual cycles again. She is annoyed, he is annoyed, right, he is annoyed. He is traumatized that I am in a different person's body. My treatment for this family was educating the family about gender and sexuality related topics. It took me many sessions. Now Dylan and family are getting along well, but at that moment, what would you do before you hit the breakthrough, you know, like, she says suicidal, dad brought her in, intake paperwork says suicidal, right, so that was my whole question again. The last one, okay, 12-year-old Ukrainian refugee has come to the U.S. for the first time with his mother. Mom was a CEO of a baking company back home in Ukraine. Father and the older sibling who is 16 years, because he meets criteria, was not allowed to leave the country. Mom and kid were able to leave, they've come to Chicago, they hear from dad and mom maybe once in three weeks, maybe once in two days, maybe two times within a day, sometimes on the phone when they do a video call, it's only the dad in full military gear, son sometimes in full combat gear, when they do the phone call, the dad and the older brother are trying to encourage themselves, saying it's okay, it will be an honor if I die for the country. Bombs and words like that. Now this kid who is going to school is starting to talk about bombs and dying. The school has been helpful, but this kid saying bombs and dying is having a contagion effect with the other kids at school, in-person school, right? The school said, we tried to handle it as much as we can, but we still have to follow our zero tolerance policy, if somebody talks about bombs and explosives, we just wanted him to get checked out. So the kid is here in my office, I don't even know what to do. My heart is almost crying, because this mom and son and family, you know, it was heartbreaking. But in any case, full question, what would you do? So that was my last case. I have two quick studies to show, because these were the things that I wanted to look into some data about, and I looked at the acute care hospitalizations in the U.S. for the last 10 years. This was a study that got a lot of media attention. It was also written about in New York Times. The two take-home points would be 25% increase in the proportion of mental health hospitalization amongst all pediatric hospitalizations. And the hospitalization for attempted suicide and suicidal ideation and self-injury increased from 30.7% in 2009 to 64.2% in 2019. Point being, this is also pre-COVID, right, 2019, that's until then. So I was starting to look at, are there anything new, or, well, always by local, right? So I wanted to check what's going on in Illinois. So I found this from the American Academy of Pediatrics. This paper from 2016 to 2021, as far as I know, this was one of the first papers to talk about or cover that COVID-19 period as well. And in short, the most important point here would be there was a 57% increase in hospitalization from pre-pandemic fall to fall of 2020. If further data is being collected, then it might show even more spikes in 2022 and 2023. Those are the two spikes I would talk about over there. Discussion points, well, bigger spike, I already told you about that. Total emergency room burden went up. Ground reality is that few, very, very few hospitals are actually covering inpatient psychiatric hospitalization anymore. I wouldn't be surprised if some hospital decided to shut down their inpatient psychiatric hospitalization this morning. This is what I struggle with. Do I send them to the emergency room? No psych beds and disposition plan. What is going on? I don't know. Social media, pandemic, isolation, more research needed, effect of other social determinants of health, no outpatient research data available, which is very difficult. Because even in downtown Chicago, I know many of the other child psychiatrists for various reasons because insurance is not paying well and all that. I don't even know how many people are dealing with the same issues. We cannot collect data for outpatient. We are very few. Amongst all specialties, if you looked at the, like, you know, which specialty we have the highest shortage of doctors or physician workforce, it's psychiatry, but exponentially higher in child psychiatry, especially during the pediatric mental health crisis that's going on. I leave it up to my fellow presenters to continue to talk because I don't want to take up too much time. But I hope I've given you some perspective of this. This is what I would like for you to focus on, especially the students, residents and early career psychiatrists, learn how to be comfortable handling suicidal ideation and other acute care issues that may show up in your outpatient practice. Good history taking will always help at an individual level, right? Nothing better than that. At an institutional level, see if you can avoid inappropriate deflections to the ER. If possible, analyze data within your institution. At a city or state level, please collaborate, collaborate, collaborate. Pediatrics needs our help. Adult psychiatrists need our help. Collaborate with policy makers and identify community partners and resources. At a national level, of course, APA, you guys are all here. So let's collaborate more. Let's do something about this. Thank you. Thank you, Sid. So you can go ahead and have a seat. I want to ask you a few questions and we'll get... Okay, go ahead. You don't have to talk directly into it. So first of all, raise your hand if you knew in the audience that behavioral health is frequently reimbursed at around 60 to 80% for the exact same codes as primary care. Did anyone know that? Some people guessed it, but not everyone knew it. Raise your hand if you knew that a lot of psychiatrists and a lot of child and adolescent psychiatrists who are in an outpatient setting don't accept insurance payments at all because pay is so low. Yes. Okay. And raise your hand if you suspect that access to care is somewhat limited for struggling working parents who have insurance but can't find a psychiatrist who will take insurance. Okay. So clearly we have a problem with our system. And so, Sid, may I call you, Sid? Yes, please. Okay. You can always call me, Sid. Well, just... Okay. Can you all hear me okay? Okay. Thank you. Yeah. Okay. So what would you suggest? Is there anything that you think could be done to try to improve parity, to try to improve reimbursement, maybe to encourage more providers to accept insurance? See, it is we who have to work towards that, right? Once we identify the problem, then you have to advocate. Without us advocating, it is not going to change. Will it be done on its own? Absolutely not. Can it be done together? Yes. I was at the legislative conference for ACAP on the Capitol Hill trying to advocate. I also try to tell my friends and folks to say, you know, get involved with advocacy. That's how it will be done. Without advocacy, it cannot be done. Right. So we have parity laws, but those parity laws are basically a pinky promise, because they actually have to be reinforced, and insurers aren't out there advertising what they pay people, are they? No. And can we ask other providers what they're getting paid by insurers? No. That's technically illegal. So the system is actually set up to be adversarial, and unfortunately, kids, adults, parents in our country is sort of caught in that conflict. There was a child psychiatry fellow that I spoke to. I'm also the chair of the Early Career Psychiatrists Committee on the Illinois Psych Council. So I talked to many of our youngsters. So I asked her, like, what do you want to do after working? And she said, I want to be a cash-only practice. Why? I said, I hear they don't pay well if you take insurance. And I have student loans. That's what she said. That's the most appropriate way of saying that's what she said. And that is actually very common, as you all know. Sid, do you think that any of the cases that you brought could have been solved with AI? So I've been looking into this. My brother is doing a PhD at the University of Virginia. And one of the things he's trying to do is emotion recognition using AI and how it can be used in pediatrics. So there is some data to say something called an EMA, the emotional something assessment, which you can use like wearables and track on their phone and all that to collect data to see if a kid can become or is becoming suicidal. Is there some way you could collect that data to identify who's more at risk? Could be. But that's where the social determinants of health comes into the picture. How am I expecting this migrant Hispanic kid to have a wearable? How am I expecting this patient that comes from the south side of Chicago? I mean, it's there is a gap. Yeah, I, I asked that question half jokingly, I think that perhaps one day AI could do something like that. But Sid, I think that the one thing that you did in those cases was you listened. And I think that you built a relationship. I think that you had to do it very quickly. And you had to do it in an environment that was not necessarily set up for building a very quick relationship. And even though screeners are good, tools are good, the relationship is vital. And remember, the patient with the alleged eating disorder had been in a unit for a month. So he had a chance for a month to connect to someone, and apparently didn't, because he was apparently able to cope by restricting, but when the restricting failed, he was no longer able to cope. Okay, so now I am going to switch roles. Okay, so now I am actually going to, to be presenting Dr. Nibiru's presentation. I will tell you a little bit about myself before I tell you a little bit about him. I am a child and adolescent psychiatrist at Children's Hospital Los Angeles for half of my job. And for the other half of my job, I am a chronic pain specialist for children at CHLA. So I wear two hats. I think with the same brain, there's a lot of feedback, sorry. I wear two hats, but... I have nothing to disclose, any sort of financial interest. Dr. Nibras is a consult liaison psychiatrist at the Texas Children's Hospital. And this is part of the Baylor College of Medicine. And he has no financial disclosures. And his objectives were to describe ways that youth suicide intersects with pediatric health care in general across settings, and to highlight challenges faced by a child and adolescent consult liaison and inpatient teams. So as Sid pointed out, there are multiple studies that show that there are a lot more kids expressing suicidality, presenting to emergency departments, presenting to clinics, presenting to school nurses, presenting to school therapists. Raise your hand if you think the emergency department is the best place to address suicidality. Good. It's probably not the best place. It is a safe place at that moment. But obviously, it's not ideal. All right, brief statistics. This is very number heavy. And I personally am not a numbers person. But this is not my presentation. So suicide is the second leading cause of death for teens and youth ages 10 to 34. And around 25.5% of adults aged 18 to 24 report having seriously considered suicide in the past month. That's higher than any other adult age group. 18.8% of high school students responded to having seriously contemplated suicide in the past year. That percentage is higher amongst females at 24%. And lesbian, gay, bisexual, and transgender teens at 46.8%. 8.9% of high school students attempted suicide in the past year. And that percentage is highest amongst females at 11%. Black teens at 11.8%. And lesbian, gay, bisexual, and trans youth at 23.4%. Looking at trends, we can also see that several different factors are increasing over the years. If you look at the years 2009 to 2019, the number who experienced persistent feelings of sadness and hopelessness increased from 26% to 36%. And remember, this is also pre-pandemic. Seriously considering attempting suicide increased from 13.8% to 18.8%. Making a plan increased from 10.9% to 15.7%. Attempting suicide increased from, I think, that's 6.3%. The numbers are small. To 8.9%. That's the problem with having old eyes and a younger person, major slides. The number who were injured or who had to be treated by a physician did increase. It was thought not to be significant statistically. But then again, the numbers are so small that it's hard to know exactly was that a change or not. All right, so this is specifically the Texas Children's Hospital data. I'd like you to look at this top graph. This demonstrates the behavioral health emergency consultation, meaning the consult liaison psychiatrist was called to the emergency department and see how it dramatically increased in quantity during the pandemic and has not died down yet. If you look at the number of sitters who were required to be at bedside in the emergency department, that also has increased dramatically in the past few years during the pandemic. In January of 2019, it was in the single digits. January of 2023, it is in the triple digits. And you see the red is for suicidality. Blue is for aggression. And green is for danger of elopement. So we have a huge increase in suicidality in emergency departments. So data from the 2011 to 2020 National Hospital ambulatory survey of emergency department visits examined the mental health-related visits for youth ages 6 to 24. And the number of mental health visits increased from 7.7% to 13.1% or nearly double during that time. Suicide-related visits had the greatest increase. The proportion of mental health reasons increased significantly in all sociodemographic groups, including age, sex, race, ethnicity, insurance type, and geographic region. Over the past 10 years, the number of pediatric ED visits from mental health has doubled. And there has been a five-fold increase in suicide-related visits. So the Joint Commission released a national patient sentinel event alert. And the way the Texas Children's Hospital responded is a collaboration with psychology, emergency department, and psychiatry to screen all youth who were being admitted to the emergency department. They screened youth who were medically stable, conscious, verbal, not intellectually disabled. They used an electronic version of the Columbia Suicide Severity Rating Scale via tablet in the ED room. They made it confidential to improve accuracy. And they made it integrate into their EMR, which I think is probably the biggest work of art ever because my EMR could not integrate even what I'm typing in, let alone something else. And it was approved by the IRB. The reason the Columbia Suicide Severity screen was selected is because it measures severity, intensity, behavior, and lethality. It has excellent internal reliability. And it's commonly used in pediatric patients. The demographics were 42% male, 57% female. And you can see the ethnic breakdown. And I asked Dr. Nibris, and he confirmed that these demographics are consistent with the community and large around the hospital. And the results are that on arrival, although only 3.4% of visits were primarily for suicidality, an additional 10% of suicidality was picked up on screening. So that was 1,200 patients during this time period. In the month prior to the ED visits, 13.5% endorsed passive suicidal ideation, and 11.3% endorsed active ideation. The lifetime suicidal behavior was 9.9%. And suicidal behavior in the prior three months was 3.9%. Youth with a chief complaint of psychiatric or medical trauma were more likely to endorse active suicidal ideation, passive suicidal ideation, lifetime behavior, and suicidal behavior three months prior to the visit. Also, demographically, if you're only looking at gender, females had a threefold risk for passive active suicidal ideation, as well as lifetime suicidal ideation. So suicidal ideation and attempts in the emergency consultation pre and during COVID are a little bit different. What his hospital did is they looked at their screenings that occurred between January and July of 2019 and compared those to January and July of 2020. Out of a total of 9,092 completed screens on youth age 11 to 21, with a mean age of 14.5, across the study period, in the past month, suicidal ideation was 15.8%. And suicide attempts in the past three months was 4.3%. So this data is already higher than the data that we just saw on the previous page, because we saw lifetime suicidal ideation or behavior at 9.9%. So we know that the numbers are creeping up already for this combined rating. The demographics were pretty similar to the previous demographic slides. And the results were that there is a higher suicidal ideation in March and July of 2020 compared with March and July of 2019. A higher rate of suicide attempts in February, March, April, and July of 2020 compared to the same months, 2019. During the onset of the pandemic, stay-at-home orders and isolation was thought to be a factor. In May, there was a resumption in some social activities. But then in June, there was a resurgence of COVID. So psychosocial support was changing during that time period. Assessment of suicidal youth, as you already know from Dr. Shinoy's talk, is heavily communication-based. Without good communication, you're So psychiatric diagnoses that are commonly associated with suicidal behavior are depression, mania, hypomania, substance abuse. Children and adolescents who have chronic illness are also at high risk, especially if they have adjustment problems, anxiety, depression, low self-esteem. I'm going to throw in chronic pain. History of suicidal youth, as you already know from Dr. Shinoy's talk, is highly communication-based. History of suicidal thoughts, plan, and intent are also very important. If a patient is chronically thinking of suicide and if they've had a prior attempt, especially if the prior attempt could have been lethal. Individuals who are irritable, aggressive, delusional, threatening, hallucinating, or voice a persistent wish to die are at much greater risk. Assessment. You must ask questions. There are great screening tools, as we've already determined. The Columbia Screen is a good tool to use. You don't always have time to use screening tools in your office. You may want to just have your own set of questions. Who in the audience feels comfortable with their set of questions for all ages? Who in the audience works primarily with adolescents? OK, a good number of you. How many in the audience who do not work primarily with adolescents feel comfortable with your adolescent questions and skills? Very good. OK. I would suggest for those who are not comfortable to consider starting to use a screener and then to ask follow-up questions regarding the screening. So we have a couple of cases. The first case is an 11-year-old female with a history of depression, generalized anxiety, PTSD, who was referred by the school because three weeks prior, she had written a note to her ex-boyfriend stating, if I kill myself, I want you to know I love you. There is a typo in this, but it was a typo. But it was directed to him. In addition, she was threatening a female peer, stomping on her and taking all of her friends away. And we know that she has a history of sexual trauma, having been raped by her brother and being molested by her father. We know that she has a family history of depression and anxiety. And we know that she also has trauma from her mother passing away when she was six years old. She does have some protective factors in that she is in overall good health, average intelligence, has family support and access to health care. Unfortunately, the emergency and hospitalization processes are not easy. They can be traumatic. We can see this patient was in the emergency department for over 24 hours, then admitted to a medical hospital on the floor because there were no psychiatric units that could actually take this patient. The consult liaison team, in their assessment, determined this patient should be hospitalized. So apparently, the thoughts that were present three weeks prior when she wrote the letter were persisting. And apparently, she had a plan with potential lethality. So unfortunately, there were no hospitalization options other than the medical hospitalization and with the plan to admit the patient into a partial hospital program. But there's a flaw in our system with that as well. When someone's an inpatient in a hospital, there isn't an actual means to admit them directly into a partial hospital program like there would be, allegedly, to admit them to an inpatient psychiatric unit. But we know this patient couldn't even be admitted to a psychiatric unit, let alone a partial hospital program. So we have huge gaps in our systems of care. Another case is a 13-year-old female who lived with a single mother, was attending school, had no previous psychiatric history, but did have a therapist. We don't know how long she had the therapist. But she had expressed to the therapist that she had suicidal ideation with the plan of cutting her wrists. And we know she has a history of cutting with healed scars on both arms and her thighs. The patient was reporting depression that was increasing over the course of a week to the point of suicidal ideation with a plan. The patient had depressive symptoms, anhedonia, low energy, sleep disturbance, and had symptoms consistent with major depression, had uncontrolled worries, was restless, had a history of panic attacks, and had previously experienced sexual trauma from a family member and had nightmares, flashbacks, and intrusive thoughts. So this patient has a lot of risk factors. And her symptoms are escalating, not de-escalating. And her therapist thought the symptoms were severe enough to actually warrant an assessment. Discussion, patient remained in the emergency department waiting for an inpatient transfer. Unfortunately, there were no beds in the entire city. And this is Houston, so it's not a tiny town. She had no insurance, and so that further limited any sort of treatment options. Only one hospital in the whole city would have taken a minor with no insurance. She was eventually transferred to a medical bed and waited for inpatient until she was deemed safe. However, that admission was a very long and difficult admission because beds were unavailable. And unfortunately, there was a very long wait for partial hospital, intensive outpatient, and especially those services for uninsured patients. In addition, community clinics that could have been able to take her had up to six months of wait time to accommodate such youth. So you see, there are huge gaps, huge barriers. And although a lot of us think there are no beds, there are no beds, yes, that is true. But there's also lack of support in the rest of the system. For example, intensive outpatient services, access to DBT, which is shown to reduce suicidality, and all the services that could actually prevent hospitalization, which, by the way, hospitalization is not without its own risk. It could be traumatizing. Think of a transgender youth who's going to be hospitalized, and they have to decide where is the patient going to be roomed, with what gender is the patient going to be roomed, what name is the patient going to be called. So hospitalization and chronic suicidality are in themselves traumatic, although sometimes hospitalization is lifesaving. Discussion, obviously, adolescents and younger youth struggle with some of the same symptoms that adults struggle with, but because of age, legal status, insurance problems, cramped emergency departments, cramped inpatient psychiatric units, and huge barriers to care, as well as stigma, poor reviews, youth have a huge barrier to their access of care. And we have to work within our means now, but I think we also have to advocate on how to improve our access to care. I want to point out something also about this map. These maps are available on ACAP's website, so with the second QR code, the middle QR code, you can go to ACAP's advocacy site, and you can go to the workforce map, and you can look at your state. Although these are beautiful fall colors, I want to let you know, you should think fire, not fall. Red means a county with no child and adolescent psychiatrists at all. Orange is a state or county with dramatic shortage, meaning only one-third the number of child and adolescent psychiatrists needed to treat that child population. Yellow is severe shortage, and green is sufficient. There are only three counties in California that have sufficient. They are San Francisco, Marin, and Yolo. Everyone else is dire to severe shortage. So I recommend, you know, check out these QR codes, do a deep dive, use the information that you have. And I wonder, since I presented, do people have questions for me? Just to go to your analogy about red being fire, if you get a chance, take a look at different states, and I've done that. I was just curious how many child psychiatrists there are. And if you look at all the reds in different states, you will see the country is on fire, especially during a pediatric mental health crisis. We should be doing something about it. This is the future. The kids are the future. So I do not have a question, but just that analogy about the red being fire, and we need to, you know, it's California, the first thing I think about is, is there a fire going on? Can I take a road trip? So it just connected to me. Thank you. So since I don't have any questions for me up here, I'm going to editorialize a little bit. Thinking about Dr. Nibiru's presentation, I'm going to say that we need to build our collaboration. At least one patient was referred by a school, which is similar with Sid's cases. At least one patient, I think two, were referred by schools. So what if we built out our psychotherapy options in schools? What if we started collaborating with schools and broke down some of the barriers in communication between on-school treatment and in-hospital or community clinic treatment? Would that possibly improve access to care? Would it possibly decrease school absenteeism for students having to go to a clinic? Which is a really big risk factor, by the way, school absenteeism. Would it potentially free up parents to stay at work instead of picking their kid up from school to bring them to their clinic? So collaboration is vital, I think, to improve this problem. I agree with this. NBC Chicago ran an article about, and a video about, which I was featured on there as well, and we were working with the school district to increase resources. And frankly, politics aside, there is some funding that's going in, especially in Illinois, to improve school mental health by funneling money into the school system. We are yet to – I mean, they've just announced this, so we have to see how many mental health workers, psychologists, school counselors will get hired by the CPS, the Chicago Public School districts and all that. I don't know the details yet. Nobody knows the details yet, but there is hope for sure. What I've been doing personally is sometimes to save time for the kids and the parents, and they still should be able to make appointments, making use of the telemedicine appointment, saying, hey, ask the kid to do the appointment from school with like the school nurse or provide them with a safe space and a room to talk, and the mom or dad join in from work. Like, example, suicidal, kind of suicidal kid, I start an SSRI. I want to make sure the SSRI is not adding or at least giving the risk of, you know, further suicidality, provide them with some telemedicine appointment. Mom and dad are like, you know, the job market is difficult. I can't really take a day off of work. Layoffs everywhere. Can't hold a steady job. I say, no, no, stay at the job. What time is your lunch break? I'll try to squeeze in. So I have moved my lunch break to a different slot to give some, you know, noon and 12-30 appointments to make this happen, but we need to do this at a bigger level. Yes, school is a very good place to provide services, and that can help a lot. I'm going to say one more thing before Tapan talks. So in my chronic pain clinic, I see patients who come from a very wide area. Some patients come from out of state to see us. I'm in Los Angeles. People from all of California come because there aren't that many places in California who treat chronic pain, but there is a very high co-occurring illness in chronic pain. Anxiety is very high co-occurring. Depression is high co-occurring, and OCD, trauma, PTSD, all of those are very high co-occurring. Almost none of my patients have psychiatrists, so I end up being their psychiatrist, which is not ideal because my follow-up is three months apart, and these patients are very far away. Do I say I can't start treatment, I can't start a medication because my follow-up is so limited? No, because they live in red counties that, not politically red, but access red, that have no access to any other care. So if I say I can't do it because I'm too limited, it means they don't get help at all. Anyway, Tapan. Yeah. Yeah, interesting discussion, and I will talk more about just the inpatient side, kind of just the experience. I work at Children's Hospital in Chicago on our inpatient unit as well as our partial hospitalization program. Guess what am I going to say? Our difficulties. So talking about just the systems and starting with that is that we heard how emergencies are just overflowing, how kids wait there, how kids board, wait on general medical floors. Outpatient services is kind of our challenge. When we have to look for the step down, we want to start the right medication, we want to treat everything, but then there has to be an appropriate follow-up. We don't have in-house capacity to even treat everybody who is on our own inpatient unit. We cannot just automatically transfer them to our own outpatient because we have limited outpatient services, and that's kind of one of the barriers. But it's a circle. It's a cycle. It goes into, just starts with just some difficulties in one area, but then it just kind of spirals into something else and something else, and everybody feels that somewhere else there is a problem. Before I talk more, I just wanted to put this slide out there. It's a complex slide. No conflicts, particularly like just this kind of the talk, but I do serve as a consultant for Verasai. I have a book writing agreement with the APA and some research support from some pharmaceutical companies for clinical trials. So we'll start with the big question of like why is it important? So we saw a lot of data in Dr. Nebraska's slides that Dr. Holloway presented, and we were able to see just some kind of like just the statistics on like just the death statistics and what happens. So not going to repeat the data, but just a kind of highlight of the data is that we are talking about a terminal illness here. So when you think of the suicidal ideation, active, passive, there is a spectrum. We'll talk a little bit more about like how we do things on the inpatient side in figuring out the severity and seriousness, but it stays on the mind, sometimes becomes active, sometimes somebody calls for help. There are times when people don't call for help and take that action of dying by suicide. And those are real numbers that in pediatric population, statistics after statistics, we do know that there are kids, teenagers, who just die. So we just have to like just from the data perspective, really to me like one death is too much. So, and it's a lot more than one who died. And one of the things that like occurs to me is that like why, what happened? Because we have seen like inpatient units kind of like before pandemic that like there was always like kind of the early fluctuation and seasonal fluctuations that like we all would, whoever is doing primarily child psychiatry would agree that during school years and that there is going to be like just kind of the spike, but like then the summer months and like couple of months when school is off, like there is a little bit of the kind of like reduction in like admissions and like units have more beds. And there was like this consistent cycle for years. Those who have worked on units like for decades, some of my senior colleagues, they all, they all tell me that like for last 20 years before pandemic, that has always been the trend, which changed with pandemic. Everybody was home. Initially we did have a deep that like there was not, everyone was doing fine first few months. And we knew this was just a matter of time. And then all of those like difficulties as we saw increase in the emergency visits, increase in like just inpatient admission needs at a big time in the pandemic and still happens a little bit is that we had 20, we have a 12 bed inpatient unit. Uh, and we had 22 patients waiting on our general medical floor to get to us. And we knew that was not going to happen. Uh, I mean, they were not all going to come to us, uh, but lots of like just kind of the barriers. But what happened there? Like, I'm just like wondering about like the social perspective. We don't know that like the schools, community lives, everything was affected. Uh, but is it, is it all about that? And I do feel that there might be some biological perspective and a COVID related kind of the we do know that the COVID brain and like just some of the neuropsychiatric kind of the manifestations are real. And I, I do genuinely wonder that, like, I mean, and there are some who are trying to do this research. I don't know about in the child and adolescent kind of the space, but maybe that changed something. Maybe that did change something, which is leading to like just some kind of the increase in the need. Uh, but, but, but, uh, hopefully we'll continue to like, just not be seeing this emergency departments, like still overflowing. Um, that part has, is variable now. Like not every emergency department is overflowing right now, but there was a time when almost every emergency department was overflowing. So right now, like it's a fluctuations as we see, like sometimes they are, sometimes they are not. Um, and, and they get like just kind of like just the inpatient admissions, uh, in, in the area if they need. Um, and then, then the larger kind of the barrier is like longer term care. And I'll, I'll talk about like just how, uh, sorry about that. Yeah. So, and we'll, we'll, we'll upload this slide later. So they will be available. Uh, and, uh, so what, what happens like when, when somebody does get better, there is an inpatient bed. Now it is available. Somebody got to us. Does that solve everything? Uh, that is that, is that all about like getting to the right kind of the setting, which was like acute care, which was decided that somebody needs the inpatient level of care and we are there. And is that enough? Um, then we'll talk about like just the, what the treatment looks like on the inpatient side, but it's not, it's, it's, it's, it's a kind of like just the in between, uh, kind of the zone where we are all trying to establish as just the safety outside the hospital. So as long as we can ensure that there's going to be like some safety outside the hospital, they get discharged. So that is limited kind of the treatment on the inpatient side, three to five days. Uh, we really, really work hard on like just, uh, going deep into how bad is the suicidal ideation and for, uh, and how we can like just help somebody in gaining some basic coping skills, increasing their kind of the ability to stay safe, making a kind of the safety plan with the family. And that becomes the kind of like just the end of the inpatient admission. So they are really short. So there is not a whole lot that happens even after this like tremendous amount of the weight and the hopes, lots of reasons. Sometimes, um, we do feel that, uh, I mean, and nobody should be like in the hospital if they don't need to be, they're going to be away from the family. Child psychiatry units are not structured like any other pediatric beds. Parents are not going to be living with them in on the unit. There are visitations every day. Uh, but, uh, but, but we want like just limited to like just what's necessary. But sometimes even when we do think it's necessary, the systems wise and insurance companies wise particularly where we are in Illinois, we see significant difficulties in like getting even, um, sometimes the companies will approve one day, next day they would not approve because, uh, somehow like we wrote in our chart that kid is not suicidal today. And then I do those reviews that, uh, what, what makes you think that like something changed in 36 hours? Uh, we, we, we are not asking for like just weeks overhead. We are, we are saying that three to five days is the minimum that we need. Uh, when somebody is kind of like deemed necessary for admission from the emergency department perspective, you already approved a day. So then that doesn't make any sense that you wouldn't approve day two. So that's, that's kind of like our everyday life and we struggle with those challenges. So three to five days of the inpatient stay, what it looks like is the, there is going to be group therapy. We have recreation therapy. We have school individual therapy, family therapy. Um, and, and, and we do the disposition planning in terms of like where, where is somebody going to go next? Um, and, and what, what does the ideal kind of the outpatient treatment look like is sometimes that we wonder about, uh, that we want to help our outpatient colleagues that they, when they take over, um, there is some amount of the work done and they can continue. Uh, and, and, and the continuity of the care, uh, different providers talking to each other, um, when, when it's a kind of the handoff from like just outpatient to inpatient or inpatient to outpatient sometimes like really, really helps. Um, and then, uh, limitations we talked about are just that like, despite trying like just multiple medications, sometimes we just don't, we just don't see the kind of like just the improvement. There are still like persistent suicidal ideations, persistent kind of like just the challenges that continue, uh, over and over. And, and in, in many cases, the suicidal ideation does improve over time. How we want to track in the future is about like just the frequency, number of times it's happening for somebody and how long it stays on the mind. So the duration for each time the SI happens, how long it's lasting. So that's one of the, one of the ways that like we ask families, kids to like just track for themselves also. And that would be like one measure of like just telling us that like whether things are getting better over time or they are not getting better. Another, another challenging aspect here is the non-suicidal self-injurious behavior. Um, we've been seeing this like just, I mean, increasing a number of like just the self harm, um, self-harm occurring and like just kids doing it like more and more. And mainly like it, it entails the cutting and um, whole arm being like just full with the cuts and like just the multiple cuts on the legs and thighs. And like, we just, we just keep seeing those over and over. And that's again, like just the poor ability to cope and that, that becomes one of their coping tools that, uh, I just do that because I feel, uh, that like it's going to, physical pain is going to reduce the emotional pain. And that's 99% of the time, the explanation that we get from the kids. So the, the, the unhealthy to like just kind of the healthy, healthier coping tools, that's something that we focus on in patient level of care as well. So that when they, when they are discharged, at least like something, something, something more positive is taught to them that they can do when the next time suicidal ideations happen and when they are at home with nobody, uh, or, I mean, not, or, or without like just at least in their own room without anybody. Um, one, one thing about like just the hospital wide screening, I don't know how well at your respective places, places like you have a system or do not have a system, but many hospitals have not had like just the best kind of the system. Um, and, uh, it, it looks like the ASQ, the ask suicide questionnaire, uh, that's one of the, one of the initial steps that can be done. And there is a, there is a, sorry, again, the slides are not appropriately displayed, but like there is a, there is an article link that I have. I mean, it's not a link, but like just the article that like if you search, uh, it will come up and it has like further guidance on how you can do like just step-by-step kind of the screening outside the inpatient unit. So this is not for us. I mean, we do inpatient level like suicidal screening all the time. Uh, we have two 15 minute checks. It's a very different setting, but, uh, in emergency in a consult floor, even outpatient, like the, it's a, it's a nice kind of the article that will guide you towards like how, how do you screen? This is the, this is the kind of the brief, uh, safety plan that I was talking about, uh, earlier that like we, we want to make with like all the kids that we, we want to make their environment safe. So we teach the families that keep the sharps away, keep the medication bottles away, including over-the-counter medications, nothing that they can use to hurt themselves. It varies from family to family that how much like the, how much efforts they put and more the force the families put kids feel trapped that they're like, I lost all my privileges, I mean, everybody's watching me, I don't like that. And we explain that this is all going to be temporary, that until you have those thoughts, suicidal thoughts, we're gonna need to have just more of just kind of the measures in the home, and then as you get better, you can gain all of your privileges better, and most kids do fine with the explanation that we're not trying to take away any of your privileges, it's no punishment, it's to keep you safe. And then one really great thing, like which all of us working in child and adolescent population would agree with is just the kids do listen. They listen, I mean, they listen more than adults, they work with us, they really do kind of demonstrate the insight into just kind of when we try to help them. Some have harder time in demonstrating insight, it takes time, but we can work with them, and continue to develop some kind of the insight, and guide them into what are their own warning signs, triggers, what leads to suicidal ideation, and what happens before that, and then again, the coping skills, what they can do when it does happen, and who are the people at school who is gonna help out, who is the at-home person who is going to help out, and some resources, we try to give it to every single one, unless a six-year-old, I mean, we don't see six and seven-year-olds, fortunately, as often, just for suicidal ideation, they are usually admitted for just the aggression and lots of different issues, but the cognitively kind of just ability to understand the phone numbers, eight, nine, they are fine with having these numbers with them handy, so we make sure that they have that, so even if they have nobody around, they can pick up a phone, do a text, do something that they can do to call for help. I know Dr. Holloway before just kind of described this KC as an instrument, I really do think that that's one of the good ways to assess the severity level, it's a child and adolescent service intensity instrument, there is a KLOC, another version, and I think it's a combined KC-KLOC kind of the guide, that one was more kind of the secured and I couldn't easily just access, but the KC is definitely more readily accessible, and they define just this risk level in six different dimensions, risk of harm, functional status, co-occurring conditions, recovery environment, resilience and response to service and involvement in services, and then there are details to each kind of the levels, that how do you continue to further define the dimensions of just the intensity and just what is going on. These are great kind of just the points to document in the notes also, because the notes are getting read by just the insurance companies, and if they don't see some of the severity level, and our daily progress notes are gonna be, today kid is fine, then they will be like, why is kid in the hospital? So we have to, day after day, we have to really focus on just explaining and justifying that why we are keeping somebody from today until tomorrow. And then we spoke briefly about the non-suicidal self-injury. Intent is really the key difference over here, that they don't intend to die, but even when the intent in non-suicidal injury is not the suicide, they can, I mean, with the kids, they're not going to have the best judgment, so this is how I explain that multiple times you keep doing certain things, when in your mind, you are not trying to commit, I mean, you're not trying to die by suicide, but at the same time, you're not, when you keep doing certain actions, it could kill you, it could accidentally kill you, and that happens all the time. So that's another way of explaining to the families and the kids that take the non-suicidal self-injurious behavior very, very, very seriously as well, even though the intent was not suicidal, I mean, suicidality. Then the actual spectrum, no different than just, I think the adult world, when we try to do the suicidal assessment, we're gonna start with the intent, we're gonna get into the, if they have thought of a plan, have they done any kind of the preparation, and then if they have had actual suicide attempts that nobody knew about, or they're planning on attempting suicide. And non-suicidal thoughts, self-injurious thoughts and behaviors have just really the close association, as I was saying earlier, with the suicidal ideations, particularly in teenagers, and they have both. Usually people have not just one, they usually have both, and they fluctuate. One changes into the other very rapidly. Where is the biggest need, like where do we not know, like where can we have some impact, what are the things we have still not figured out? I really do feel that I'll tell you something that like in modern day-to-day, like when you're practicing psychiatry, child psychiatry, you wouldn't think of this every single day, but did you all know that there are, FDA approval-wise and indications-wise for depression, there are two medications, Prozac and Lexapro, low-oxidine and acetylcholephrine, that's it. So we use everything else, so we even tend to forget this fact that we have no indication for even depression. First-line depression, we have only two medications which are really carrying the actual indication. That doesn't mean there is no evidence. There is evidence for lots of other SSRIs, there is evidence for SNRI, but again, not enough to the point that somebody submitted to the FDA and gaining just kind of the actual kind of indication. So that's one barrier that even the first-line treatment, what would we call first-line, it's a lot like we need to answer to ourselves that what are the options as the first-line, and when that fails, what's the second-line, what's the third-line? So better understanding of just the neurobiology, hopefully, will continue to just kind of guide us more. But one particular area that worries me the most is not every suicide stems from underlying kind of the depression. Not every single time when somebody dies, they were just terribly depressed a day before and that's why they died. The impulsivity piece and all of a sudden just kind of the losing control on the mind that now I'm just upset and I'm going to do it and then it wasn't necessarily planned, that happens all the time. And that's a very challenging kind of an area that how do you address that? You can get depression better, you can get the mood better, how do you get the impulsivity better? And the medication targets for just the impulsivity, they tend to be limited as we know. And one area where I still call it kind of an unmet need is the digital therapeutics and there is a lot that's under development right now. Some of you might have seen some posters over there as well and a lot of people are trying for a variety of conditions, not just depression, that how can digital therapeutics be helpful and that's one of the ways, it's gonna be some AI driven kind of the models as well that they're trying to incorporate into the apps and just kind of the resources. But the chatbots, they are in a very primitive phase and we have heard terrible stories of how just automated kind of the AI driven chat is not yet very powerful. So I wouldn't suggest that. But when somebody wants to continue to work in this space, there are lots of opportunities is how I feel. And I think this is one of my very last slides. We're going to continue to just talk a little bit about systems of care. We are far from perfect, we know that. But what would be kind of the perfect system? How do each kind of just the domains and different units of the function in the society, how do we interact with each other? So family structure versus school versus health insurances, hospital systems, outpatient services, complex situations involving multiple aspects, case management, legal framework, it's a lot. So I do feel that each person ideally deserves that there is one dedicated person who is following just really all kinds of the progress because you are going to know what we did on inpatient side, I'm gonna know what you did on the outpatient side. But it's still in family's mind. Sometimes the parent who has time to just kind of dedicate into just making that kind of longitudinal kind of just the data points that helps but maybe technology can help with some of those tracking and kind of longitudinal day-to-day kind of like multiple times that we need to know how kid was doing. And ideally would love to see just data from multiple time points each day when I see between two months appointment if there is an outpatient, then I wanna know each day how it was at 7 a.m., each day how it was at noon, each day how it was at 4 p.m. Can we honor us on like just the kid or like somebody who is completing it? But at the same time, like I do feel that like there is some kind of like just the value in like just kind of the mood tracking on consistent basis. So that's kind of like what I wanted to talk about inpatient treatment, how it looks like and how we go back to Dr. Shinnoi, the Dr. Shinnoi, it's your job now and you're gonna treat them in outpatient. So it's a kind of and then families and like in the acute situation, the hope is going to come back to emergency and inpatient, but like it's all a cycle and hopefully like we don't like include the inpatient like when the improvement is there and nobody's going to admit a kid if they don't need to. And that's the only insurance companies who think that way that we would. Thank you. Three quick announcements before we do the panel discussion and take questions from the audience. So the first one is just like how he handles acute care in his role professionally, he handled the technological fiasco very well, don't you think, right? So he didn't stop, he didn't flinch, he continued to talk about it, worked with it. So thank you, thank you, Dr. Parikh. Earlier when I checked, it was working fine. But anyway, second one is the QR codes. Please, please take a picture of this. We don't know how long we are able to get the QR code because then you have to like who's paying for it and all that stuff. We are using the free trial right now. So take a picture of that. Individually, like you can zoom in later and open the three different resources because we want this to be the take home thing that you will take from here, more resources in one place. Open those and then save those as a webpage, three different links or email it to yourself, those three links because the QR codes, we're trying to figure it out. Then finally, the third one is using the APA Annual Meetings app. Please, please give us any feedback, suggestion, thoughts, rate the session and whatever you can do. We love feedback, that's how we grow. So please consider doing that. Back to you, Robert. Thank you. So Tapan, I wanted to ask you, first of all, do you work in the location that everyone's talking about? Everyone's like there are no beds, there are no beds, we have a suicidal patient who needs a bed. Tell me about the expectations that you get to change medications, solve the problem and how do those expectations actually impact your daily life in the hospital? I think it becomes, again, each state being different but where we do have inpatient units, sometimes, and it's a very positive thing, I'm very proud of what I do where I do but then there is an expectation that we are the only largest tertiary care children's hospital. There are other children's hospitals with even inpatient child psychiatry beds but we become a destination of hope. So everybody wants to be there. So then there is just kind of that barrier also. Some families refuse to transfer to other places if they're standalone, just kind of the inpatient beds, kind of the hospital, as we know there are many. They just refuse, they don't want to go anywhere else. So on medical legal basis, it's a very challenging kind of a situation where they do end up just kind of waiting on our general medical floor and our hospital is being very empathetic to not letting people wait in the ED but then when you need the inpatient psychiatry bed, going on general medical floor isn't going to be that valuable too. So that's kind of one aspect of the systems of care that it's a barrier that not everybody's going to be getting to the unit but if there are beds at some units, how do we help everybody? We all do the similar job. It doesn't need to be like our unit. We have other units on the area and progressively we get patients day after day that their families don't want to go anywhere else and we just really need to just do, and everybody does their own kind of the share and job of doing what they do but what is it that we could be standardizing so that it just becomes the natural kind of the floor. Thank you. You two work in the same city. I'm wondering how do you collaborate and how does that in fact affect quality of care? Yeah, his practice is one clinic where we have always had availability. One, yeah, yeah, yeah. So in Illinois, the early career psychiatrists, we all are trying to band together to try and help each other out and try to create unofficial ways of coordinating with each other using the Early Career Psychiatrists Committee. We have like a WhatsApp group and stuff like that and I actually see two of my early career psychiatrists, one from Springfield, Illinois, Dr. Keisha Powell over there, Dr. Mike Swierdkowski over there. We've had to unofficially talk with each other asking like, hey, is there a PHP bed open or do you know if somebody's getting discharged? I have an acutely suicidal patient. It just goes on to show that we collaborating with each other and with family practice and pediatrics will make a huge, huge, huge difference to how we deliver care. Sometimes that even breaks institutional barriers, right? Like that's the biggest thing. Everything is so disjointed. Can we do a better job of coordinating? If any psychiatrist or pediatrician calls me on my phone, I'm happy to answer anything I can. Of course, following rules and laws and everything, but I'm happy to answer and help. But that's my answer to you. I think we have to find ways to collaborate. Thank you. I know that time is short, but I wanna open up for questions from the audience. So if you wanna just make your way to a microphone or if you wanna try to project. Thank you. Hi, Brian Marku. My first year post fellowship and a child with the Navy. So I'm out in Guam where we really don't have much of anything. There's one inpatient unit locally that is more of an observation unit. They have a family nurse practitioner who will do rounds and sometimes consult with adult psychiatrists, but really not much therapy. I think they might have a psychologist who sees them once or twice a week and they're trying to start a psychology program where they might have some trainees and a little bit more. But in my clinic, I'm at the Naval Hospital and I see people who have some kind of military benefit, whether they're a family member of active duty, veterans, so a lot of locals. And for the active duty families, it's a little easier because if they're acute, I can find ways to get them off island and say, you can't be stationed here anymore. We gotta get the family off. But for the locals, it's really tough. I don't really have anywhere to send them. And I've had people go to the unit that is on island and they felt like it was traumatic or just the experience there was worse than the suicidality they were experiencing at home. So I've really run into a lot of situations where a year out of fellowship, I'm holding onto these outpatients that, if they walked in my door in fellowship clinic, I'd be like, you need to go to the ED. Why, you shouldn't be here. And I went to a talk the other day on just the IOPs and PHP model. And I'm wondering, do we need to divert more resources towards that and away from inpatient? Do we still need to be emphasizing both as much? Has there been too much emphasis on inpatient? Because I'm now kind of wondering, are there a lot of cases that we will keep admitting to inpatient, but they really didn't need that. They needed PHP or even just IOP, but we still rely on inpatient, which is very expensive. Or even DBT. Exactly. So, first of all, thank you. And I think you actually summarized the entire presentation in like two minutes, like less than a minute. So that's exactly what we wanted to convey that many residents, fellows, even me, like I had an old school attending who would say, somebody dropped the word suicide, you need to send them to the ER. That's it. But that's what we're trying to change. And one size does not fit all. You will need a village to raise a kid, but also to take care of a suicidal kid, right? We need physician-led teams, because you need the expertise. And then we need everyone possible to be our eyes and ears. And that's how we can hopefully build this continuum of care from school mental health from outside to outpatient to inpatient. Robert, Tapan, sorry. Yeah, no, I think I was just saying, there is a scarcity of PHP in IOP too, I heard that, right? That like there is no PHP. Also, you can think of, yeah, yeah, I think PHP is one of the, at least that should be available. Not everybody needs inpatient, and it could be okay, but like as long as you at least have a PHP. One second, it's 9.30, so if anyone wants to leave, we won't feel bad at all, but we are more than happy to stay back and continue the discussion. Thank you. Okay, I had a few questions, and one of them actually related to the IOP. I love the concept of PHP and IOP in my practice, and I usually advocate it as ideal choice, unless it's obviously an adolescent who's like, I don't wanna do any group, but they'll just see individuals. But for the most part, it's great. However, it's access with transportation, car, if, I mean, y'all are probably not familiar with the Atlanta metropolitan area, but there's definitely kind of a racial socioeconomic as far as where all the resources, and even the private programs, they're kind of all in the northern side of the town. South on down, it's like limited to none for child and adolescent. So I've wondered about, what do y'all think about virtual IOP, PHP? I don't know much about it, but I just remember recruiter. What are your thoughts? I mean, it's a high risk population, but it could be good. It exists. People started doing it during COVID. It is effective. The biggest problems are it's easier for the child or adolescent to escape treatment by turning off their camera or just by refusing to come to the camera. So if the kid is actually motivated and will stay on camera and participate, it should be a good option. And maybe that's an option that should be tried first. And if the kid won't stay on camera, then you need to try a different avenue. That's very real. The other brief one is, are you all aware of ketamine studies for child and adolescent for depression or suicide? Dr. Baric here. I think I followed just ketamine since its development and there are multiple ways that you can think of ketamine. I don't think anybody on the adolescent side, like in any kind of the academic, I mean, there might not be units that are doing, but like there are IV infusions. I mean, ketamine is a cheap anesthesia medicine which is like available. So IV infusion, if somebody thinks that it's going to be helpful, there are some people who try that. Some people have done it like through kind of the research, but like one that is like just really the ketamine which is approved, which is the nasal spray for the adults. That's not still like, it still doesn't get indication for pediatrics. So it's going to be very hard to access that, an insurance company to be able to pay. But like, I do often wonder about like using it off-label and that's not what we're talking about. Like, and I have no connection with like just off-label use recommendation, but like that's the only kind of the option here that like you gotta get access to the nasal spray and like just maybe try that for some of the very severely ill kind of the kids. And I do often wonder about that. Just on the same topic, what do you think about RTMS for kids? I think the TMS is the same story that like, I mean, there is evidence, but like the insurances are not going to pay for it and it's an expensive treatment to pay out of pocket. There is no indication. So there is no FDA approved indication for TMS here. Is it for IV ketamine? I mean, is that still helpful? IV is cheap, but like I think IV like requires like somebody to be like really feeling comfortable. I do know exact doses and like how we can do IV, but even then like other colleagues and like everybody like this, when I talk about like just the IV ketamine that I want to try on this kid, it creates like kind of like a scare that like, how are we going to do that? And what are we going to do that? But I think that's certain situations where like I'm thinking of like one or two particular like kind of the teenagers, they'll die is how I feel. That like, if we don't do like just everything we can, they'll end up like just dying by suicide. So those are like kind of the situations that I would do anything I can think of where there is like some rational kind of the basis. And this ECT is the other one to like just consider not every place is equipped to do pediatric ECTs. There are state laws which are going to be barriers and that's another one to like just really consider when it comes to severe depression. I would recommend maybe if you have an academic institution trying a pilot study and doing a case series, if you have access to that. You mean for the nasal ketamine? So the company's not looking to pursue that? No, I think in my understanding, they are pursuing as far as I know. I think they are into clinical trial phases and following like just whatever the typical FDA regulatory processes. I think they are pursuing as far as I know. And any recommendations for digital therapeutics like specific brands? I know you can't give official, but any y'all actually like? I think not, I like that a lot as well and I follow the trend, but like I don't know if any of you know, but like the digital therapeutics is like going to be approved the same. I mean, not the same way as the medications, but there is a pathway now. So like in 2018, FDA created this kind of the digital therapeutics approval pathway. So since then, like there are people who are submitting the apps that can be actually FDA approved for the intervention. So there are a lot in development. I get contacted by multiple companies that like would you be a site for that digital intervention kind of the trial? So it's happening right now, but like I don't think there is any app which is like really kind of like just the evidence-based right now, but then there are like tons of apps as we already know. And I don't know if there are any which are actually good, except for like some mindfulness apps are good. I think I've heard of them, but other than that, like just real kind of like CBT driven or like TBD driven or some real digital therapeutic kind of intervention that's still in development and a lot of hope there. I think that can really be helpful. Dr. Tapan Parikh is also on the ACAP Psychopharm committee. So he's a great resource for all the questions that you asked. Good morning. I just wanted to really to first thank you for this wonderful presentation. I found it very enlightening and I'm certainly experiencing everything that you discussed where I practice, but I would like to comment that I have gotten TMS approved for a 16 year old. Wonderful. So I would encourage you to actually talk, I spoke to the medical director of this particular clinic in my area. And so I think if anyone's considering it, I would encourage that. And then for anyone who's in the DMV, I can give you details on the program that I worked with. Did they have private insurance? Actually, they had TRICARE. So I was really surprised, but what the medical director told me is they have gotten other approvals for TMS. This did require the mother sending in a letter, but it only took us about, I would say maybe a month or so between the company putting in, kind of sending in some letters and then the mother. Yeah, thank you. Dr. Parikh, there was a question from a med student. She had done a poster about all the FDA approved drugs in the last five or seven years. And her question was, she had heard about something called ovality. Does it, does it help? I mean, we spoke about. What's the, what's the, what's the pharmaceutical name? It's the dextromethorphan combination. That's something. Yeah, I haven't, I don't have any experience, but I don't think there is pediatric indication yet that that would be. For the adults though, I've heard. For the adults, yeah. The trend says it works faster. It has, it has like just kind of like the scientific basis and actual clinical trial data that suggests that at least like that's how, that's how it has gotten approved. So we'll, how the trend usually goes is that like, I mean, usually we're gonna see like at least adults being on it. And like, if it's helpful, it will come to child psychiatry world. And a real, real question and barrier would be like cost. If automatically it just take over the period of time, company reduces and like it goes down and people can like afford without bypassing. I mean, without any insurance, because the insurance companies are not going to approve. So they are, they are, they are major. I mean, that's going to be the major barrier in like just trying anything. But again, that's another one where, you know, very severe cases that like, I would, I would want to try that. It just, just, we just don't have otherwise like any, any hope for like, there are some of the very sick, like kind of the teenagers I see with multiple suicide attempts. Dr. Swiatkowski, just one second. On the same lines, I have a question for you. Every time I wanna start an antidepressant on an outpatient basis, parents ask me about, I know this is a whole different grand rounds, if you, if you may, parents ask me about, is the medication going to make my kids suicidal? Yeah, so I think, I think we all gotta be like, really, really prepared to answer that one. So I'm going to tell you like what my, what my usual spell is and like what I tell the families. So first of all, there is clear like FDA black box warning, but you gotta, we all gotta know and memorize this, memorize this right now and like that, like what it exactly is. Increase in suicidal thoughts and behavior. These are the wordings of the black box warning. Increase in suicidal thoughts and behavior, not the suicides, first of all. That's the black box warning. So some people basically have like worsening of their suicidal ideation and suicidal thoughts and some behavior also, it does get worse. So how I explain is that I take a paper, I will draw a line that somebody's already like kind of on the path of like declining, right? That like they are declining, declining, depression is getting worse, so they are gonna decline. Their suicidal ideations and thoughts and behavior are gonna get worse anyways. Give medicine or don't. You see somebody at that like kind of the time point, then there is going to be like that kind of the decline. So, but like when you give the medicine, even then the decline is the kind of better than not giving the medicine and it's not driven by those kind of the studies. So it's not, the black box warning is not driven by comparative studies of treat somebody versus don't treat somebody, pick 100 kids who you treat, pick 100 kids who you don't treat and follow the suicidal ideation and behavior. That's not how the warning came. Sometimes this like kind of the post-marketing kind of like just the warnings just happen because of lots of like reporting that like when people report, the FDA has an obligation to like just kind of the issuing of the warning. So it's a statistical kind of a tricky question and then there is like exact kind of the numbers. I think it's a 2% versus 3%, so I tell that also that somebody who was not, I mean, it's a kind of a 1% difference that we are talking about. So I think if we tell all of this and plus like just my clinical science that like I'm not against again saying that like I'm going to exactly tell you what the warning is. I have to tell you this is my job. But if I thought that your kid is going to get worse than like going to be more suicidal, I wouldn't be giving it. Robert, is that only for the SSRIs? Because that's what my patients always say. It's all antidepressants. Yeah, it's actually a general warning. Yeah, it's what I call. And it's another thing to tell them that it's not about just this medicine. It's a class of, if you call anything antidepressant, this warning will be there. And it also applies to anticonvulsants, especially gabapentin, pregabalin, other medications too. Dr. Swiatkowski, you've been patient. Thank you so much. Thank you all for the talk. So I work with adults. But I suppose I have some thoughts about children. I like that you emphasize that when you give SSRIs, it's an increase in suicidal thinking because I generally take an existential view to my therapy and philosopher Albert Camus says, the only serious philosophical question is the question of suicide. So it's probably something that everyone in this room has questioned at some point. And then the treatment, emphasizing that this could be an increase in suicidal thinking as if there's already some baseline in even healthy people of suicidal thinking at times. And I like that you've also emphasized there are layers to this, that inpatient is like the highest layer. There's PHP. My question is basically, are there any programs that you are aware of or any space for physicians that you see in introducing DBT or psychoeducation into the curriculum of schools so that the first time a patient comes to you in the clinic, they at least have had some exposure to therapy concepts or DBT? That's the question. I think therapy concepts like more widely kind of available are gonna be like just kind of the CBT, but not necessarily DBT, but then there are like teenage DBT programs. They are just kind of like probably overflowing, but they are there. Like DBT programs are there. And schools is a great area of just improvement. Schools are overwhelmed with just every day what they are doing. Schools vary based on geographic location. Some are just in underprivileged kind of the areas where schools don't have the same amount of resources versus some of the neighborhoods. So that kind of varies. And between entire school, how many even guidance counselors they have? Do they really have licensed social worker or do they even have RN? Like lots of questions that like who is going to do that? But I agree that like we could probably like embed like some of the curriculum and simplify CBT and DBT kind of the principles and like just how do you still like introduce that? And it goes back to like probably digital therapeutics that like somebody wants to probably develop at least like some kind of the app like where you are going to give that basic kind of the education. Kids will love it. Like it would be a fun kind of like the way of learning. But schools is a big question that like how like they are going to be able to without the resources. I think they would need significant support and like just kind of like just the funding just dedicated towards like mental health in the schools. I appreciate that. I wanted to chime in on a study you might look up. So if you were just to Google quiet time Bay Area school, there is a pilot program that existed in a local Bay Area school looking at students who either participated in quiet time in their class once a day or I think it was like 15 minutes, no speaking, no looking at screens, nothing. If they didn't want to do nothing, they were allowed to read. And the kids who participated in quiet time had a dramatic improvement in their grades, their emotional health, behaviors, suspensions and expulsions. It was a dramatic improvement and the kids who were most at risk had a bigger benefit than the kids that were less at risk. So there are things like that that the schools can do relatively easily. There's not a lot cheaper than just be quiet for 10 minutes. Yeah, that's a great way. And I think just the, it becomes a question of like whether you call it late introduction of the therapy or like you're just going to call self-help because it's a self-help kind of the tools that are going to be like more readily available and we can teach those that like how can you cope with stress and all of those things. But the real kind of like just the concepts of like just the CBT or any psychotherapy, I really do feel that it's a individual, like one-to-one kind of the most strong kind of like just the relationship-based kind of like just the building. And I have a very, very low threshold for like just recommending therapy to not just kids but the adults also. So I'm a big believer of like that individual connection because that person who is going to be taking the role of the therapist has no interest in other than like getting that person better, of course they get paid, that's different. But like apart from that, they don't have any other kind of the incentives and it's a very, very kind of like just the relationship which I value a lot. So like I think, but I think your question is stemming from like lack of resources and we just start seeing like things getting way worse so what can we do before that? But the replacement to like individual like one-to-one therapy, it's kind of hard to imagine because I'm a big believer of like just one-to-one individual therapy. Okay. So, oh yeah, please, please come to the mic so it can be recorded as well. Before that question, let me say, I want to acknowledge Dr. Sohail Nibras as well who worked hard on this presentation but just like we need him in our psychiatric workforce and he's been holding down the fort in Texas. That also goes to say how much shortage we are. Go on, please. Hi, I'd like to start by saying thank you again for the presentation. I found the topic very relatable to my experience as a resident psychiatrist in Hawaii. For a little bit of context, we serve the entire state and we only have 14 inpatient child beds and the average wait time for IOP, PHP is like one to two months minimum. So I've run into the issue where I've gotten very comfortable in the emergency department finding reasonable, lesser restrictive options but the outpatient providers are scared and understandably so but I really have to be judicious about who I'm admitting because we're so limited. So do you have any recommendations as a resident and hopefully a future child fellow in navigating these discussions with providers? First of all, I think welcome to child psychiatry. I think you are already in the process of making that decision to be a child psychiatrist. We need amazing doctors like you and everyone else to join our workforce, right? Okay, so the question, Robert, do you want to take it or do you want me to? Why don't you start and I'll join in? Okay, so the way I have been telling residents is your biggest tool that is available to you is your mental status examination. No better tool than that. The best tool is here and we have to make use of that despite workforce shortages, availability, non-availability of resources, everything else, that connection to your patient is going to be the key in making that decision about who do I send to the ER? Who do I not send to the ER? You know, that connection will immediately bring you the other two connection or like at least one connection which is the caregiver, mom, dad, or. Use that as your first resource in your planning the disposition while on your feet over there and follow up. What I've been doing is if I feel like on the edge about a patient, I do my best to give them an appointment within the next two days. And I've been giving them like post-work time. I'm like, let's add one more patient. So that's what I've been doing. I wish it was not like that, but we are the ones with that privilege, luxury, power, and you know, that special place as a physician first to help this kid or anybody. Well, first of all, I want to acknowledge Dr. Park who has to leave for another presentation and thank him. I was gonna say real quickly, find a mentor. Mentorship is amazing no matter what stage of practice you're in. And there may be someone near you. And if they're not, you could do, because of technology, you can connect to someone far away. Before Dr. Parikh leaves, which presentation are you doing right now? It's at 1030 actually. I'm just being obsessive about getting there sooner and setting up the PowerPoints. But yeah, it's on a clinical trials methodology. If you have any interest in clinical trials, please come join. It's on the second floor. I think what room it is. In 209, 209, yeah, so 209. Do you have a follow-up question? Yes. I just wanted to say as an outpatient provider, thank you for squeezing patients within two days because that is so hard to find. So it puts a lot of accountability on us on the inpatient setting. So thank you for doing that. And I hope that I can, you know, I have the space to do that myself one day. I would love to continue to connect. There are a lot of child psychiatrists in the audience too. We'd love to talk to you. I have one more answer to your question. Start collaborating with pediatricians. They are desperate to know how to prescribe, how to assess. You can do some basic teaching and start collaborating with them officially and unofficially. Was there another question? Doctor, you had a question, comment? Doctor, you had a question, comment? Yeah. Okay. We would love any feedback. Please rate this session. And thank you, Robert. Can we give a round of applause to Robert for putting this together? And for your.

child mental health

adolescent mental health

fragmented services

accessibility issues

suicidal ideations

inpatient resources

minoritized groups

stakeholder collaboration

adolescent suicidality

emergency healthcare

mental health assessments

safety planning

resource integration

therapeutic options