Thank you so much for being here, so early in the morning as well, so, and not a bad crowd, so I really, really appreciate it. So today we're going to talk a bit about the future of suicide prevention, and I have a lineup of great speakers on this topic. So my name is Diana Clark, and I am the managing director of research and senior epidemiologist and research statistician at the APA. I'm also the president-elect for the International Academy of Suicide Research. So anything suicide and suicide prevention is very dear to my heart and to all of us here. So I'm going to present on suicide and suicide prevention across settings. My colleagues, Dr. Posner, is going to be presenting on screening and connection to resources and suicide, and Dr. Adair will present on protecting workforce burnout and suicide, and Dr. Akendo is going to be our discussant, so she's going to wrap it all up for us, and then we're going to open up for Q&A. So here are our financial disclosures. Give me a second, okay. Okay. And instead of spending time describing and introducing everyone, I thought I'd just put a very brief bio for everyone and, you know, just get into the introductions, into the presentation so we can have more time for that, and we can get to the discussant and then the Q&A, because we do want to hear from you. Okay. So whenever I do a presentation on suicide, I really do like to start off by defining suicide, because for a long time in this field, there was no unified definition of suicide and suicidal-related behaviors, right? So suicide is death caused by a self-directed, self-injurious behavior with an intent to die as a result of that behavior, and it may occur in response to many kinds of intense, painful, emotional, distressing, and intolerable situation that are experienced as intractable and leave the person feeling trapped. So the basic criteria is the act must be self-inflicted, intentional, and the outcome must be death. And then as we talk about suicide, we need to also talk about suicide attempt, right? So these are the non-fatal, self-directed, potentially injurious behaviors with an intent to die as a result of that behavior. But in addition to talking about suicide and suicide attempt, we thought it was also important and the field thinks it's important for us to also think about these other suicide-related behaviors. And the reason for that is they are as predictive of suicide as suicide attempt. So the interrupted attempt, that is when a person takes steps to injure themself but is stopped by another person, right? And so the interruption may occur at any point during the act, such as after the initial thought or after the onset of the behavior. Aborted attempt, this is when a person takes steps to injure themselves but is stopped. So this is when they stop by themselves. And then you have perpetuatory behaviors. So it's when the person take the time to think about it, take the time to start preparing for that, making that suicide attempt. And so some of the terms, and I do find some seasoned suicide researchers, suicide prevention researchers still using them, but some of the terms we are really, as a field, trying to push for us to stop using these terms. Simply because they carry some negative connotation to them, committing suicide. And you can think about commit as if you're committing a crime. And for many years in many countries, even here in the United States, suicide was a crime. And so you can understand why that term came about and why it's important for us to move away from that. And there are still some countries in the world that still consider suicide a crime and punishable. Successful suicide and failed suicide attempt. So these are our failed suicides. So these are some of the terms that we're trying to educate the field about avoiding their use. So suicide occurs across all regions of the world. It occurs across the lifespan. It affects individuals of different ethno-racial backgrounds, socioeconomic status. It's just pervasive. It's across all groups. And it affects approximately one million people each year, which means that approximately every 40 seconds, one suicide attempt, one suicide occurs. And in the U.S., we found that approximately 48,000, 49,000 people die by suicide. So that's one death, one suicide death every 11 minutes. And if we think about suicide, and we think about the other suicide-related behaviors, these occur even more frequently than suicide, right? So about 12.3 million adults seriously thought about suicide. 3.5 plan a suicide attempt. 1.7 million attempt a suicide attempt. And the numbers for the interrupted suicide attempt, the aborted suicide attempt, and the preparatory behaviors, those are even very prevalent as well. So suicide was among the top nine leading cause of death for people aged 10 to 64. So you can actually see that it does impact individual in that, you know, you'd be part of their lifetime when they're, you know, moving into adolescence. But now we're finding out more as well that individuals younger than age 10 are also dying by suicide, and in certain groups more so than others. And as I said, suicide rate, it occurs across various groups, and it vary by these multiple factors. So age, sex, race, gender identity, etc. And the causes of these behaviors are very complex and requires a multifaceted approach when we're thinking about suicide prevention. As I said, suicide occur across many different settings. Suicide is the second leading cause of death in individuals age 10 to 24. This age group accounts for 15% of all suicides. And when we think about between year 2000 and 2021, we saw the suicide rate in this group increase by 52.3%. And it impacts some groups more so than others. So the groups that's most affected, we see, are the American Indian and Alaskan Natives. In 2021, nine percent of high school students reported attempting suicide in the previous 12 months, and this was especially among girls compared to boys and among the non-Hispanic American, Alaskan, sorry, American Indian and Alaskan Native students. So this is just really a graph kind of showing you that suicide and suicide attempts occur across, and suicide-related behaviors have been occurring and they increase over time, and that how the, if you look at the graph, that, and the graph, the blue graph, sorry, the blind, so we're looking at suicide ideation. Then we look at suicide attempts, and then we look at suicide. So we see that the suicide occur, ideation occur more frequently than the suicide attempt and then the suicides, right? And somewhere in between all of these, you'll have these other suicide-related behaviors. So when we're thinking about suicide prevention and intervention in schools, it's such a captive audience that if we can actually work with the schools to implement different type of suicidal, suicide prevention programs, how beneficial that could be because of the age group that's at that high risk for suicide. And so when we look at a meta-analysis, you see that school-based psychoeducational intervention coupled with screening, referral to clinical care, doing suicide prevention in a community setting, it tend to have this, be effective in reducing self-harm behavior and suicide ideation in this group. Okay. So when we think in terms of, in the healthcare setting, approximately 22% of individual use any services in the weeks leading up to their deaths. And less than 10% use any specific types of services. Right? So here, we're just kind of showing you the different settings, healthcare settings, where individuals show up for care. And so here, I'm sorry, this line here is actually showing the weeks prior to death where people are actually showing up for care prior to their deaths. Right? So they're showing up in the emergency room. So this, because so many people are showing up in the emergency department for suicide, for care prior to their suicide death, then it makes sense that this is a place where we can actually implement prevention activities. And so having brief patient education and safety precautions is important, conducting universal or even selected or even targeted screening and providing these at-risk individuals with a full assessment, full mental health assessment is important. And then even providing brief interventions while the patient is in this ED. And so if you're going to discharge that patient from the ED, developing a suicide safety plan is something, and studies have shown, that given those patients that developing, working with that patient collaboratively to develop that safety plan, have the patient feeling safe because they have this thing and they can actually use an activity they can implement themselves if they feel at risk. And then ensure careful discharge planning and safe transition. And the one important piece too is the lethal means counseling, very important when patients are presented to the ED. And then looking at, doing the screening, identifying those at risk. And then one of the things we always stress as well is that, yes, sometimes people might screen negative, so the clinician has to use that clinical judgment. So looking at all the risk factors that are there that are present. So here we look again in the primary care setting. And as you can see, even more patients shows up for care in primary care setting to their primary care provider within the weeks prior to their death. So the primary care setting as well becomes an important setting for suicide prevention. So if primary care setting can establish protocols for screening, assessment, intervention, and referral. But if they're referring, we need to also make sure that we have the workforce to provide the care. Because when you talk to primary care providers and providers in, I do work as well in perinatal mental health. And what the non-behavioral health providers talk about is, yes, we might identify the risk. But if we don't have the resources to refer these patients to, then we feel that there's a disadvantage to even screen. So we need to make sure the workforce is there to provide the care when suicide risk is identified in these settings. So one of the things that's suggested is the training of all staff within practices about suicide care and protocol, including suicide safety plan and lethal means counseling. Create agreement with specific behavior health practices that takes referral. And then, of course, making sure to talk about the national suicide prevention lifeline and services. Suicide occurs in outpatient mental health settings. You are there and you'd see this. And you're also seeing that they do present even more than I thought, you know, significantly more, quite a bit in the week leading up to their suicide. And yet, they're being missed. And so, in these mental health settings, it's important to, the screening is important. If you have these patients that are coming in, because we know that suicide, having a mental health disorder or even symptoms is an important risk factor for suicide. So screen, screen, screen. And using that simple, yet effective suicide safety plan is so important. So why, and suicide risk assessment is so important. So why is it important? So we talk about the one death every 11 minutes. We talk about how suicide is affect, affects individual across different groups. And we can work together to help prevent suicide. But we need these accurate assessment and screening in order for us to do proper treatment and intervention. But we have some challenges. There are variability in the assessment methods or tools. Some tool, we have a lack of culturally informed assessment tools. And we do, this I hear a lot where clinician worry about the risk stratification because they think it's, the screening tools are too inaccurate to be useful. So we need to find a consistent way of screening, of assessing suicide risk. But we also know that patients tend to, sometimes they might revise, have a revision of their risk. And this is identified in a, in, in patient setting. And so that, that's part of the reason why this repeated screening and repeated assessment is important, and your clinical judgment. So if the screen is negative, what we emphasize is the need to look at the clustering of risk factors. I know the prediction of suicide is difficult. But if you can identify and see and understand the clustering of risk factors, so you can do more detailed screening or even implement, develop a suicide safety plan, it's simple, it's brief, it's non-invasive, means restriction counseling, very important, right? So it takes, it doesn't take a lot, in a sense, to do these simple things with the patient. So, you know, there's care pathways, multiple ways to do this. And this care path, suicide care pathway, talks about identifying the person when they present for care screening, doing more detailed assessment, and when they're identified at moderate or severe risk or in crisis, doing the suicide safety plan and the lethal means counseling. I actually say, even if they're identifying and it's not necessarily moderate or severe, and your judgment thinks that, say that this patient might be at more risk because of the clustering of symptoms, implementing a suicide safety plan is important. And as part of that and some work we did with the Center for, CMS, Center for Medicare and Medicaid Services, we developed some quality measures related to suicide risk. Assessment, and one of them is about assessing screening and then assessing patients for suicide, but not just doing it one way or the other, but doing it as a whole. So we developed some quality measures related to suicide risk assessment, and one of them is about assessing screening and then assessing patients for suicide, but not just doing it one way or the other, but doing it as a whole. So we developed some quality measures related to suicide risk assessment, and one of them is about assessing screening and then assessing patients for suicide, but not just doing it one time, because that's not sufficient, but repeatedly assessing the patients over time, at least quarterly, or if it's indicated more, then you would do it more frequently, but at least quarterly, and so you can track and monitor this patient over time. So even just knowing that your patient have a risk for suicide and just asking them about it, it's something that most patients, when we do talk to them in different focus groups that they find that very comforting. So here's the specs for the Suicide Safety Plan that we're just saying you need to screen, use a validated tool. Here we recommend the CSSRS. And you're using it to screen, to assess the patient, repeating it over time, and track and look at patient change and symptoms. So you can actually inform your clinical management. We also recommend the Suicide Safety Plan. And many people tell me they do Suicide Safety Plan. And when I talk to them in some behavioral health, I'll find that there's still some people are still doing suicide contracts, but they're thinking it's Suicide Safety Plan. So we need to do more education around that. And some people do the Suicide Safety Plan, stick it in the chart, and think that once it's done, they don't have to do anything. The patient get a copy, it's in the chart. But we know our life situation change. So our patient's life situation will change as well. And so we need to review and update those Suicide Safety Plans over time. And here in this quality measure, we're suggesting at least quarterly or more frequently if clinically indicated. So here are the specs for it. And so these two quality measures have become part of CMS's Quality Payment Program. And so when we developed these quality measures, we developed it for individuals 18 and older. And since we have developed them and they became part of CMS's Quality Payment Program for 2024, they've asked us to update it to individuals age 12 and over. And so we've done research on this. And so hopefully for 2025, it will be for individuals age 12 and older. So in summary, suicide and suicide attempts and other related behaviors should be assessed independently and in combination. These behaviors impart clinical public health burden. It occurs across multiple conditions. But we need culturally informed suicide risk assessment and reduction in the variability of suicide risk assessment tools. There are too many suicide assessment tools out there. So we need to have some reduction in that. And if we can find that consistent measure, we can have a common data element that allow us to understand suicide behavior more. And then of course, a quality measure can be utilized once we have this common method to drive standard of care. Thank you. So let me just start by saying, you know, that this is not a problem of youth, of veterans, of the elderly. This is our shared crisis of humanity. Takes more lives than car accidents. 135 people are affected by every death. And these effects linger across generations because of the silence that often follows. But here's the very good news. We actually believe that this is our preventable cause of death. We just have a lot more work to do. So I'm just going to add to what we know about the rates and what we've learned. And it's been a bit of a roller coaster. But you know that in 2019 and 20, we saw our first reductions after 20 years of increases. Okay, 6% even during COVID. But guess what? Those reductions were only among white Americans. Where we were seeing crisis and new crisis was among minorities and our most vulnerable. Just to bring that point home, you know, the CDC told us that five-year-old, five to 11-year-old suicide has increased, but only among black preschoolers. It's now the number one cause of death in Asian American Pacific Islanders' youth. You know, you can see all these black youth under 13, two times as likely to die than as their white counterparts. And we know that screening actually is and should be the spoke, you know, the center of the public health approach, right? It facilitates each of the spokes all around it, right? And this is very key when you look at these spokes, right? Because one of the largest meta-analyses that we've ever had, 67 studies, found that the majority of suicide victims have never seen a mental health professional and have never been diagnosed with a mental illness, okay? So Dr. Clark spoke about the Columbia. So let me talk about why it's become the global common data element, okay? Well, one of the first reasons is that it's able to identify who's at imminent risk. Pretty much for the very first time. And what are the components of that? One of the breakthrough game changers of this tool has been intent to act, okay? When you have intent to act, look at these studies. That's the number four on the Columbia. Risk goes up 1,400%, 600%, 400%, unbelievable science that supports that. And Dr. Clark spoke about the full range of behavior. Do you know that an interrupted attempt, you know, when somebody pulls somebody off the ledge, in non-psychiatric patients was four times as predictive as an actual attempt. And these other behaviors are equally or more predictive than an actual suicide attempt. So before the Columbia, we were missing all these things. And let me just put some numbers to that. Without asking about that full range, we would miss 9 million serious suicidal behaviors per year. This also, you know, informs regulatory policy. If you look at joint commission, it says get intent to act. So this is really the, you know, a snapshot of the potency of the science behind the questions. And you can see this. So it has unprecedented science, really, 600 studies, 50 of which are predictive, and all over the world, right, across settings from prisons to schools. And this, again, has been one of the major defining features of it. You know, this elusive goal that we've been chasing for so many years of identifying imminent risk before we didn't know who to worry about. So that policeman had to take everybody to the hospital. And what that does to healthcare and to the public health is unbelievable. You know, the Cherokee Nation said it very well, that its ability to risk stratify helps you improve access to services. So you can triage your wait list better. You know who needs what right then. And I'm not just talking about behavioral health. I'm talking about food banks, transportation, et cetera. And, you know, you mentioned youth, Dr. Clark, and, you know, we have these national guidelines. Screen for depression after 12. Screen for anxiety after 8. Don't screen for suicide at all, as if they're just going to come tell you. Look at this study. Six to 12-year-olds had the same odds of being high risk on La Columbia as 13 to 17-year-olds. And screening did not increase year length of stay, meaning we have to do this everywhere, okay? So we have to only treat high risk like high risk. So this is an example from the app. When you get a lower moderate answer, it says a mental health referral may be helpful. Because when you treat people that don't need it, like they're in crisis, there's terrible sequelae. So for the first time, the Columbia screener has predicted death by suicide. That has never happened in the field before and in an imminent risk time frame. So Dr. Bjerberg, in a large study, 18,000 ED patients in Sweden, it predicted death by suicide one week, one month, and one year. And a recent large systematic review and meta-analysis showed that unlike most scales that have little utility in detecting or ruling out death by suicide, the CSSRS had the high utility in the ED population for suicide risk detection. And you know what? This liability barrier that we all worry about, these imminent risk thresholds has even helped with that. Because the Columbia has so much science, it's been written a lot about it helps with the liability protection. But look at this. When MIT had a suicide, like every university did, the Supreme Court brief wrote about the Columbia protocol as the reasonable standard with the high risk answers, a four and a five. So what does that do? That frees up the teacher, the roommate, the parent to be able to ask without that liability barrier. And how does it relate to guns as well? So you know that two-thirds of gun deaths are suicide. And I talked about the public health approach for a second in the beginning. And we know that that guy who goes up to that gun counter to buy that gun to end his life does not want to die and does not know there's help. So we've been doing a lot of upstream work with the gun community for a long time. That gun shop worker can have the questions, it can be on the wall, it goes around the gun lock. And 90% of shooters have suicidal issues. So it's a way to find them. You know the Parkland community, they speak more about this as much as they do about guns. It's a way for early detection. Police are using it as part of their risk protection orders to determine who should get a gun, who should not get their gun back, right? Because we can detect who's at imminent risk. So what is the high cost of not screening or doing threat assessment as upstream as possible? You know, $510 billion in economic cost in suicide. This is Dr. Gibbons, you know, a general emergency department out of Colorado. Prior 400% increases in hospitalizations, 300% increases in ED visits. This was out of New York, four hospitals, 61 to 97% of student referrals did not require hospitalization, right? They did not require the level of containment cost and care entailed in that. And that's costly, traumatic to kids and families, and less effective in getting them where they need to go. So in schools, you know, all states have education policy from the Board of Ed, but this is Connecticut. They legislated the Columbia. But in this document, you see, right, we're traumatizing children with this exposure, waiting for hours, et cetera, those who are not actually at imminent risk. And we know this early identification, I mean, World Health Organization says, right, it's one of the main, most important things we need to do. So what are some of the benefits of universal screening, and why do we need to do it? You know, I don't need to tell you, over 50% of people who die by suicide have seen their primary care doctor the month before they die. Two-thirds of adolescents who show up to the emergency department who've tried to take their own lives are not there for psychiatric reasons. If we don't make this a vital sign, we will not find the people suffering in silence. But we have to have this concept well beyond the doctor's office, because many people never get to the doctor's office. And look what happens. Listen, large-scale universal screening, this is VA, it improved treatment engagement and mental health follow-up by 60%. Over 10,000 patients in a high-volume ED, it did not touch ER length of stay. It increases comfort levels. It de-stigmatizes the people asking and being asked are more comfortable doing so. And Dr. Akendo's, you know, critically important study that just came out in JAMA showing that 20% of people at risk don't have a diagnosis, right? So if you don't universally screen, you won't find them. This is another example, 10 years and up, every dental visit, right, everywhere this is and should be being put in. And it doesn't matter what agency, do you know that FBI, every crime scene investigation, they use it to triage every street corner. And you know, what Israel said is that this is not only saving millions of lives, it's changing the way we live our lives. This is their quote, it's a vehicle for cultural change, because if you can talk about suicide, you can talk about anything. It gives voice. And you know, why, so what it's doing is avoiding a lot of unnecessary interventions. Only 1% of people on the Columbia have a high, are high risk, right? And why is that so vital? We know that when you get out of the hospital, it's the time of greatest risk. And we know that people, fear of being hospitalized can increase non-disclosure. They feel coerced and that increases the risk of suicide attempt, right? And so maintaining people who are not at imminent risk outside of outpatient, in outpatient and outside of inpatient is so vital. We know that people who receive the lowest level of care in the community have better outcomes. They ask for help more often and they have better quality of life. Now this is just a snapshot of the outcomes, but it's really inspiring to continue, you know, the work that we all need to do. So Centerstone is the largest provider of outpatient community healthcare in the United States. You know, they reduced suicide 65% in the first 20 months, while they reduced ED recidivism from 40% to 7%. You know, and they brought it to life by telling a story about this guy who they called a few times and he said he was fine. He said, the last time you called me and asked me those questions, I was on the bridge. The importance of asking beyond the doctor's office, you know, atrium, 50% reduction in one year, you know, Air Force family health clinics reduce suicide and versus PHQ-9, look at all those false positives that get reduced. You can see all the reductions in suicide and all the reductions in re-hospitalizations, re-admissions, diversions. Oklahoma saved millions of dollars by reducing unnecessary bed days, okay? So you know, the U.S. Army and the Behavioral Health Data Portal, they reduced unnecessary overnights by 41%, also saving 30 to 40 million dollars. It's not about the money. It's about when you have all that noise, you can't do what you need to do to save the lives we can. And then this connects to well-delineated, streamlined care pathways. You know, Centerstone said it well. It's like with so many patients, it's like mining for gold and Columbia is the sifter with this very streamlined, you know, tracking and alerting. So if you get a high-risk 1% answer, you go into the crisis pathway. And we actually know that this multi-tiered two-step trigger into the Columbia or whatever is not what we need to be doing, okay? Because then you miss people at risk. Look at this study. This was in diabetes care. The PHQ-9 failed to detect nearly 50% of patients who reported suicide risk on the CSSRS, Cleveland Clinic, and most importantly, you miss the people you need to get at. So what the Columbia does is give you screening, risk stratification, and triage all at once. And we know that we have to have a public health model. The medical model is narrow. The public health approach is broad. I told you about that meta-analysis. I like to think of it as, you know, a synergistic partnership between the medical model and the public health approach. So the public health approach finds you the right people to give your important care to. Look at this, Magellan, right? When they did it with EMTs, it increased voluntary hospitalization by 66%. That's what we want to do, right? And you know, World Health Organization, again, says we must transcend the medical model. This was an urgent memo out of the Pentagon saying just this. We must put this in all hands because people don't get to the doctor. You know, and the Marines were the first ones to test this, and they used data. A legal problem was the number one precipitant in the Marines for suicide. So they put it in legal assistance, financial aid counselors, clergy, spouses. It helped them lower suicide that year 22% as well as domestic violence, alcohol, sexual assault. And that's what communities all over the world are modeling. And we know that we can put this in all hands. We just have this thousand people, veterans, elderly veterans, okay, they can be taught to do this, they can ask, and it's doable, feasible, and safe, and that it's so, so critical to what we need to do for upstream implementation. Now, this is also critically important. This is Colorado, they have great data, but most states have the same outcomes, and most countries, look at this, 80% of 10 to 18-year-olds in Colorado end their lives in their home. 75% of people in the United States who end their lives, adult or child, end their lives in their homes, and then park, you know, playground, okay, and we know we have to have this public health approach, find people where they work, live, thrive, and learn, so we have an app you're gonna be hearing about. We have to get in the homes. You know, parks puts the Columbia on the side of the, you know, the ledge, et cetera. We have to have this full-on public health approach like we've done with lots of other things, like smoking and seat belts. You know, Dr. Clark talked about the common, the common method of detection. There's been this long-standing identification with global agencies that the lack of a common data element has been one of our major impediments to suicide prevention, and just now, out of our National Suicide Prevention Strategy, right, we need standard definitions. We have to have common data elements, and one of the things that the Columbia also does is help us make sense globally of what works and what doesn't. This is one example, right? This study used the CSSRS to identify cities and geographical areas, zip codes, with increased concentrations of high-risk people, right, and the public health implications for identifying geographical environmental factors is really critical. There was an important new study called Enigma out of 21 nations showing that frontal lobe deficits in suicidal and depressed youth, and the reason they're able to do that is because they all use this same method, and, you know, Dr. Clark spoke about it being CMS, but lots of other agencies, you know, talk about the need for a common data element, and this is it, you know, and FDA says, right, if you use other things, it increases noise, et cetera, so in all the national repositories, and what's happening across these states is the linking of system across the continuum of care, okay, and just one example, so every policeman in Connecticut has this little sticky pad with a QR code, so look at the zero suicide state example. Fourth grader, mobile crisis confirms, gets to the hospital, and that more timely intervention was dependent upon that common method of detection, and state after state has said, you know, that we've lowered suicide since doing this, and why? Because it's connecting the right people to the care they need. It is the gold standard in youth, lots of, you know, meta-analyses and things that show that this has the most rigorously tested, predictive, discriminant validity, and among the highest sensitivity, and again, I keep talking about upstream, and what does that mean in schools, and we know that policy, so this is a state policy, but like I said, 80% of youth and their lives do it at home, so how do we have implementation and policy that gets in every parent's hands? This is out of the state of Connecticut, as I said, they legislate, but a memo, right, this improves the kind of uniformity that we need to do, and what happens is, a country takes a problem, and they do a study to address it, so this was many years ago, Chile, right? Given the high rates in adolescents, we need to, and their reluctance to seek help, we need to develop proactive, effective strategies to detect individuals in non-clinical contexts, right, and they do a study, and that kind of informs this massive global database that helps fuel our public health work, right, and we know, we know that with youth, and minoritized youth in particular, we have to go, they don't want to go to the doctor, right, so we have to build these creative partnerships with rec centers, community-based organizations, churches, and you know, you spoke about, you know, accessing risk factors, so this is minorities, you know, they're LGBTQ, parental rejection, hate crimes, so those particular risk factors go on the risk assessment version, and I spoke about liability, right, and it's really been broken down with all this science, this is another thing out of Pennsylvania, you know, a Google alert we got, Pennsylvania Department of Health found important, they didn't do the Columbia, they get in trouble, okay, so minimum standard of care, you don't get into trouble for a bad outcome, you get into trouble for not doing something, or what they call negligence, and you know, lots of things that we know will be innovative thoughts, a suite of mobile apps, apps that help people get to resources, utilizing big data and machine learning, predictive modeling, small bite-sized training nuggets, push data over social media, et cetera, et cetera, and the final thing that I'll say is that, you know, the Columbia protocol is policy across all 50 states, across the continuum of care, pretty much most nations, but it's used not only to save the lives of citizens, but also the workforce, so this is, for example, every firefighter in Texas, they used to screen civilians, but also identify members in the department, or family members, so I talked about this app, and Department of Homeland Security modified the app for them, so if you're Secret Service or TSA, it connects to their helplines, but look what the article said, this is like nutrition and physical fitness, this is wellness, this is how we take care of our workforce, and when you do that, it de-stigmatizes, it helps us do what we need to do. Now, we're all mostly in healthcare, right, so look at this, you know, it's the number one cause of death in male medical residents, nurses, so at our hospital, for example, all 10,000 residents got that card, it connects to their local helplines, Cleveland Clinic now customized the app for their entire system, so that it connects to their EAP, we need to take care of our workforce, and help save their lives as well, and we've been talking about the minority issues, did you know that black male physician suicide is double that of white male physician suicide, so it's another issue that we really, really have to address, so, thank you. Thank you. Good morning. So Dr. Posner preempted. One of the questions I was going to ask all of you is prior to her talking about the app, how many of you were aware that there was a Columbia app? So I see one or two hands. Not a lot. All right. All right. So I'm going to talk a little bit about workforce, workforce suicides. I'm going to spend most of my time actually talking about what we have done in PA. So I'm going to spend most of my time actually talking about what we have done in PA. So one of the things that you've heard fairly consistently from Dr. Clark's discussion to Dr. Posner is the fact that unfortunately there are a number of suicides that occur across the world, but here in the United States. The suicide rate among workers in certain industries and occupations was significantly greater than the general U.S. population. The occupation groups with the highest suicide rate were construction, maintenance and repair, arts, down through healthcare support. And this data gives you the exact rates in numbers. This data is from 2023. So it is an issue within just about all occupations. And Dr. Posner just talked about physicians in general in healthcare and actually, well, I don't have a specific slide about it. Psychiatrists are also not immune to suicide. So approximately 93% of healthcare workers were experiencing stress. We all know that particularly the last four years since the beginning of the pandemic, and I don't know about you, but for me, the last four years really has been a blur. So sometimes when I talk about what happened a couple of years ago, I think to myself, was it really a couple of years ago or was it 2020 or was it even last year? But we know that a lot of healthcare workers, particularly those within working in EDs who were exposed to individuals who came in with COVID and then the fact that they witnessed the suffering of those individuals and the fact that those individuals were not able to be with their loved ones and the stress that that took on, excuse me, everyone. So very, very important issue here. Within healthcare workers, there are several contributing factors. The workers that are at the front lines, job factors such as low job security, low pay, the stress of the job, and then also different working conditions, the risk for exposure to infectious disease, as well as violence within the workplace. All of these factors contribute to an individual's sense of wellbeing and their degree of emotional distress. So as I said, I'm gonna talk a lot about what we have done in Pennsylvania. So I am the chief psychiatric officer for Pennsylvania and I get an opportunity to spend a lot of time working with people like Dr. Posner on a variety of things. So in 2022, Pennsylvania elected a new governor. When Governor Shapiro came in the office, we had several state employees under his jurisdiction who died by suicide. So the governor made a determination that we needed to do more. And what that more consists of was our working with the Office of Administration, which has HR functions under it to ensure that individuals, particularly at the supervisor level, have training in suicide prevention. This is something that, you know, I've actually worked in PA government for over 30 years. We had never had this at this level. At the state hospital level, all employees had to be trained in suicide prevention, but never at the state executive level was there an undertaking to train supervisors in suicide prevention. So the governor wanted to make sure that if there was an individual who was in distress, that the supervisors were able to recognize, able to at least start an intervention and refer those individuals to the Employee Assistance Program. With that, the other thing that we are adding to it, and I do have to admit, this has not occurred yet, but I am this close to having it happen, and that is that the Columbia will be available for state employees who then want to utilize it as a measure of what we're doing at state government. Obviously, the screen is available so they could utilize it outside of it, but the state government, the plan is to officially make it so that it's available, and then the results can be tied to the Employee Assistance Program so they would be able to connect. And so, during this talk, we've talked a lot about the app. I particularly have talked a lot about the app. You can actually go, whether you have a Droid or an Apple, can go to the App Store and download it. A couple years ago, so in 2022, when 988 went live, we actually met with the developer and Dr. Posner because we decided, state level, that we wanted to upgrade the app to ensure that individuals were able to go into the app and that they have to opt into it. And when they do that, we actually went in and created some demographic information, and I'll show you some of the results of that that allows us to be better informed. We all know that suicide data, it lags, right? So the latest data is available is from 2021, although the CDC did just recently release provisional 2022 data. But through the app and the demographic information, we are able to look at, really in real time, what someone's particular struggles are with their risk factors, and we believe that will help better inform us in suicide prevention. So when you go into the app, there are questions that are asked that help determine the individual's level of risk, and then depending on where they then score, whether they are low, moderate, or high risk, then there are options at the end where the person can be referred. So just gonna flip through this. This gives you an idea of the questions in the next steps there. Thank you. Alright, so from a demographic standpoint, we asked the, really the kind of usual demographic information. We know that, and I should point out, these, the app has been utilized across the state of Pennsylvania, but it's fairly early, so the numbers aren't real high, but it gives us a sense, really, of what is happening, and there are points within it that we can, that aligns with what we know about suicide and suicide risk. So this graph shows you the range of zip codes across the state. You will see two particular spikes. Those spikes are zip codes that represent two very rural areas in PA, so we know that individuals who live in rural areas are at a higher risk of suicide. So the age demographic, again, no real surprises here where we see the, which age, which ages responded and, to it. The one very good thing, at least from my standpoint, is as an older individual, we always, and I'll speak for myself, not necessarily for those in the audience, we don't always consider ourselves very tech savvy, but this shows that individuals, including individuals over 65, were willing to use the app. From this standpoint, you see that there were individuals who were, belonged to the LGBTQ community who responds to the app. Really, again, and further on, you'll see some data that shows what, how they scored as far as risk factors. On the app, individuals have the ability to respond to these demographic questions or to reply that they prefer not to respond. Pennsylvania has a population that is roughly 13 million, 82% of Pennsylvania is Caucasian, about 9 to 10% are black or African American, and depending on where you are located within the state, the percentage of people of color will be significantly lower, but this gives you an idea as to how many individuals responded to the, who utilized the app and answered these questions. So when we look at risk, again, the app breaks out low, moderate, or high risk. Dr. Posner told you that with the app, I'm sorry, not with the app, but with the Columbia, that the data shows that roughly 1 to 2% of individuals score at high risk. Obviously, these numbers are much higher than that. Again, the numbers are low, and what I believe is that as the app becomes more widely used, that we will see these numbers shift down, but obviously, this is something that we are very interested in taking a look at. This shows that, at least those individuals that responded, that individuals who belong to the LGBTQ community, 85% revealed that they were at high risk, actually, interestingly, there were none at moderate risk, and 15% at low risk. Again, we're early in the stages of collecting this, so these data, I suspect, over time may change. One of the things that we are working on in PA is around, and Dr. Posner and Dr. Clark talked about suicide risk in individuals of color, and Pennsylvania, like several other states, currently has a project that we're working on to help reduce black youth suicide. This data reflects a fairly even distribution in low, moderate, and high risk of the individuals who were black who responded. When we combine individuals who are, when we look at individuals who are black and LGBTQ, this number, which, again, this number, I would actually put an asterisk beside, because this was a single individual, so, obviously, they're high risk. And then, again, this goes back to the zip codes in the rural area, where it was a very high percentage. This is the other zip code. The importance of this, for me, is the, shows the importance of doing the screen, number one, but number two, the availability of the app makes it very easy for people to get in touch, to do a screen, and the app allows the individual, then, to connect to local resources, whether it is the, they're a veteran and connect to veteran resources to 988 or the local crisis. So with that, I will conclude, and we will, I'm going to turn it over to the moderator. They did ask me, though, to make sure that when we get to question and answers, to remind everyone to use the microphone so that the questions are clearly able to be recorded. Thank you. I just wanted to add one thing to what Dr. Adair said about the app. Now, across all 50 states, whether you're a youth, a veteran, or a regular citizen, it will connect you to your local resource closest to your zip code. And again, the importance, again, most people end their lives at home leveraging this technology, you know, to get in every home, I think, is of critical importance. Good morning, everyone, and thank you so much for coming to this session. I wanted to make a few comments about the presentations this morning, and also to spend a few minutes talking with you about some of the shifts, if you will, in the way we think about suicide that I think our speakers have really underscored. One of the things that I wanted to mention is the importance of governmental action, and I think that in Dr. Adair's presentation, the efforts on the part of Pennsylvania are really laudable, because really, the countries that have been able to make the biggest impact on suicide rates are countries where mental health policy, by policy, the government actually takes action to prevent suicide. So I want to commend. I'm a little biased, too, because I'm at the University of Pennsylvania. But anyway, I want to commend Dr. Adair and his colleagues for doing that. I also wanted to mention that Dr. Posner's presentation, I think, really underscored for me the importance of thinking about the risk for suicide not being concentrated in depression and in borderline personality disorder, which is where our diagnostic tools guide our view. And of course, depression is extremely common, and so that is a very big reason why it's commonly seen accompanying suicidal behavior. But I think the time has come for us to think about suicidal behavior as something that is requiring a specific intervention. There's been a lot of work done, excellent work done, to, for example, train primary care doctors. In Europe, this has been done a lot. Train primary care doctors to treat depression. And you do see an impact on suicide rates. But I would argue that that's not enough, because sometimes suicidal behavior happens outside of depressive episodes, even in individuals who suffer from depression. And as Dr. Posner mentioned, it sometimes happens absent a diagnosis. And about 20% of the population that makes a suicide attempt do not have a diagnosis that can be detected by an interview, an epidemiological interview. So I think that is a really critical issue. And so maybe I can just spend a few minutes talking about, because Dr. Posner and Dr. Clark talked about this, the issues around suicide prevention in different settings. And one of the perhaps best studied and most powerful interventions that we have is a psychosocial intervention, which actually can be administered by people who are not physicians, not Ph.D. level. And in fact, we are using the safety planning intervention in Mozambique, where we're training community health workers to do it. And in fact, I was actually trained together with the community health workers by Dr. Greg Brown of the University of Pennsylvania, who's one of the developers of this intervention. And honestly, the community health workers were able to learn it much better than I, because they don't have other types of interventions in their heads that can, if you will, contaminate the intervention. And so I think that that's really good news, because we have a very, I think you saw the data that Dr. Clark presented, the data that Dr. Posner and Adair presented. We know that this is a very, very large problem. I want to just describe the safety planning intervention, because oftentimes, there's a lack of clarity about what it is, and it's a very specific tool. The goal behind the safety planning intervention is to help the patient develop a plan for what they're going to do, should they become suicidal. And like many great ideas, this tool was developed, incidentally, by Dr. Barbara Stanley of Columbia University and Dr. Greg Brown of the University of Pennsylvania. Like many great ideas, the tool is simple and really obvious, but that's what makes it really impactful. And the whole idea is to train the individual to use mostly distraction to help with the suicidal ideation. Think about how different that is from the way we usually think about how to solve a problem. When we're trying to solve a problem, we usually think, I better think about this really hard. And in the case of suicidal risk, the opposite is true. What we want to do is help the individual redirect their thinking away from whatever it is that's driving their suicidal thoughts. So the first thing that the person who's doing the safety planning intervention with the patient is to hear the story of what happened. Because it's very common, I think Dr. Adair mentioned this, oftentimes people don't have anyone to talk to about this and they're really relieved when they can talk about it and you're not afraid to talk to them about it. So it's to hear the story about what happened. And the reason that's important is that patients are often unaware of their triggers, especially if they struggle with suicidal ideation chronically. And so helping them understand that when they have an argument with a parent or with a romantic partner or they have trouble at work, that they can start to identify things that happen to them in their environment or that they experience in their environment that might put them at higher risk. The first, the safety planning tool has six steps. The first one is to engage in behaviors that can help the individual be distracted from their suicidal thoughts. And it may be going to the gym, listening to music, watching a movie, any number of things and that list is developed individually with the patient. The second thing is to engage with other people who can help the individual distract themselves. So for example, maybe get on the phone and talk to someone who is interested in the same sports that you are, follows the same team that you are, talk about sports. Or it might be again, you know, if you have, if the patient has a friend who likes to go running with them, call that friend, go for a run. So again, distraction now with the assistance of another person. The third step is to help the individual identify persons in their environment, in their community, in their circle, who they feel they can talk to about what they're going through. So at this point, you're starting to get into this whole notion of having people in the environment who are comfortable talking about this and Dr. Posner and Dr. Adair talked about this in their presentations. And the fourth is to call the individual who is taking care of the patient or to call emergency services or what have you if the first three steps don't work. And finally, but not the last thing, the lethal means prevention is really critical. So asking questions about whether the individual has pills at home that they've been stocking or that are dangerous, having guns either taken out of the house or at least put under lock and key, finding out if the individual has access to, I mean, some of the things are very difficult, right? So for example, if you live in a house, you're going to have knives as long as you cook. So things like carbon monoxide poisoning, jumping from heights, even the self-asphyxiation can sometimes be very difficult to prevent. But again, having a conversation with the patient and ideally, I think maybe Diana mentioned this, Dr. Clark mentioned this, ideally also engaging the family so that they can help with getting rid of some of these risks. Another very important thing, especially if you're doing this kind of intervention, if it's being done in an emergency setting, is to make sure, Dr. Clark talked about the importance of connecting individuals to care once they're discharged from the hospital or the emergency room or whatever. We all know that that is easier said than done. And it's very common for people to be discharged from the emergency room or the hospital and not have an appointment for another two weeks, sometimes a month. And so having contact from the setting where they were last seen, and in some of the work that we do, we actually make phone calls or send texts. And they're amazingly helpful to the individual because a lot of times they respond to that in terms of feeling like there are people who care about them. Many times these individuals, as you all know very well, are quite isolated. So I think that I wanted to describe the safety planning intervention and it's something that is transdiagnostic. It doesn't matter what other psychiatric condition the person has or if they don't have a psychiatric condition. And I think its utility is really enhanced by the fact that it can be administered by lay individuals. And just to give you a sense of its utility, in the last study that was published in the Veterans Administration, which is of course a very high risk population, there was a decrease of 50% in suicide attempts after discharge from the emergency room when this intervention was used. That's a very large effect size. So I'll stop there and invite people to come up to the microphone and ask any questions. Thank you for your attention. And I wanted to add that it also has an app. And you know, Dr. Arquendo spoke about the importance of governmental policy. So many states and agencies actually pair the two. So Columbia and safety planning, you know, and that's a really important thing to do as well. And the quality measure, yeah. Can you hear me? Hi, good morning. Can you hear me? Yeah. Thank you for this wonderful discussion I think it's something very close to the hearts of all of us who practice mental health in some way or the other I come from Singapore. I am Dr. Avichandran. I'm a psychiatrist from an emergency department of a large psychiatry hospital in Singapore and Usually my take-home is from APA is like, you know, all these insights we have already know known but I think it's like when we when we put it across in a platform and discuss I think it's like you really like start thinking about more of the ideas and things which we do And this is very close to my heart because suicide prevention is one thing which we have been striving to do for many many years We always aim for a zero suicide Rate, but I don't think we have really really achieved that so the few things you talked about especially standardizing the Suicide risk assessment and prevention methods. I think it's that's something really very valid One of the things I wanted to just point out was like in in terms of the mental health conditions We always talk about depression as one of the main things which is associated with suicide but we have also found during our mortality more morbidity rounds discussions that Anxiety actually plays a big role there Especially the anxious distress that happens to people because when they are in they are really in a Situation where they are caught they don't know they feel trapped. They don't know what to do So that helpless situation that anxious distress is one of the main reasons that possibly standard way of assessing, and CSSRS is one of the best, I would agree. There have been some other centers which are using other suicide tools, suicide risk assessment tools, but I feel it gets very diluted as we try to understand how the process works. So that's one thing I wanted to talk about. One question I wanted to ask was, you know, we want to recruit more of the support system for them, the support that continues in the community. How is the handover done? We do what we have in our system is we do a warm handover to the families, to the support they have, the community resources. How is the warm handover done in your settings? So it'll be something which I can take back to my department. Like, how do you ensure that this person is handed over to the support system that they are going to continue with? Well, I'll just say from a continual risk monitoring detection standpoint, this is a really important point. And Dr. Stanley used to say, you know, we have to do this every contact because, God forbid, the time you needed to ask is the time you didn't. So the Columbia becomes a method for continuing to monitor, which is really critical, and also a way to connect, right? So it's built into those warm handoffs for that consistency. Just from a detection point of view, I'm not sure about the intervention. If you had something to add. I was hoping that the panel could use it. How does that warm handoff occur in your clinical setting? How do you ensure that they're normal? Go ahead. So as I said, it's easier said than done, right? Because, you know, if you're working in the emergency room, good luck getting an appointment for the next day. And right. So I think that one of the things, I think it was Dr. Clark who mentioned the importance of building relationships with community clinics or community practices that will accept your patients. And having agreements with them is one step towards doing that. But it is a huge challenge, and it creates for emergency departments a very difficult situation with recidivism when patients don't have another place to go. I do think that there are, as telehealth continues to grow, that we will have access for, Dr. Adair mentioned, rural communities where access to care is just terrible. And so I think we need to focus on expanding. But your point is very well taken. Thank you. And I just wanted to add, too, that countries are customizing the app, too. We can talk about this after Ukraine, et cetera, et cetera. Yeah, I also wanted to ask you if it's possible to share your slides. They were really wonderful. Thank you. The last comment that I will make about that is my SAMHSA colleagues would be remiss, and they will remind me of this if I didn't say this, that the other thing with the advent of the certified community behavioral health clinics, that is an avenue that will help get people and make those linkages that should end up happening. But as already been pointed out, it is difficult, and it is an area that we really need to do more work on. And we just simply need to build our workforce. There's a great need for building our workforce. And when I talk about building our workforce, yes, psychiatrists, but I'm also talking other behavioral health providers, and creating them so we can have that wraparound service. I find that that's not. So we need to have not just the emergency department and the hospital and the psychiatric clinics, but we're talking engaging with social services. So we need to have this wraparound care so that we can have that kind of handoff when we identify patients that are at risk. But if we don't have the workforce, or if we, you know, I like the idea of the training of non-behavioral health providers to take care, to do some of these cares. I came from Toronto. And one of the things that I remembered in Toronto, which I thought was kind of interesting, and when I came to the States and I mentioned it, they thought nobody understood it, that we had the GP psychotherapists. So these were physicians who went back and did a master's in psychology, mental health counseling. And so they, as physicians, they actually had the ability to also see the patient for mental health care. And the reason why they did that in Toronto was simply because mental health care, going to see a psychologist was not covered, even though we had universal health care, was not covered by our health care. And so at least when we had these GP psychotherapists, patients had better access to care. So that was kind of an interesting thing. But if we can just educate, develop, strengthen our workforce, more collaboration between different behavioral health providers and different groups, I think that's important. Thank you for putting together a wonderful program and presentations. And as a Columbia person, thanks for basically an advertisement for a Columbia product. Oh, dear. When I was a first year resident, my first patient, when I was a resident in an inpatient service, comes in because the police brought him when he was ready to jump off the Triborough Bridge. And when I asked the person to get their history, this is my first patient as a first year resident, he said what happens is he was at the bridge, ready to jump. The police showed up. And what did they say? Don't jump or I'll shoot. Think about that a little bit. Fast forward 20 years, I become the chief of service of an outpatient department right up on 59th Street. And as Dr. Akendo said, things get really complicated in terms of you could have the best app and the best data. However, you have to include things such as, I don't know how the app covers things like catchment areas or insurance coverage or who is in the family or is there alcohol and drugs. God forbid the patient is under the age of 18 and there's no bed in the whole city to admit somebody to. So that's what I mean, it's complicated. And then you have the training factors. You have a person being treated by a resident and then you have a resident in the outpatient department and then you might have a disconnect between the two. And then you have each of them has a supervisor and over the supervisor, you have a chief of service, which would be me on the outpatient side, arguing with the person in the emergency room and then it gets shot up to the chairperson when there's a disagreement and that's Dr. Akendo. Worst case scenario, nobody wants their name connected with the suicide that winds up on the front page of the New York Times or the New York Post or the Daily News. Okay, that's the worst case scenario. All right, so I said I'd get to a question. What is the evidence that a brief hospitalization impacts the course of something over the course of either months or years of suicide? You know, we're talking about a low risk, I mean, it's a low percentage behavior or whatever. If someone gets it, is there a study or a analysis showing that a brief hospitalization actually makes a difference? That's my question. I can't think of any offhand. Not that I know of. I think the main issue, Dr. Heiler, is that when confronted with a patient that is acutely suicidal, I don't think many of us would take the risk and I don't think an ethics board would permit it. Good morning, thank you very much for an excellent presentation to all the panels. I am from Venezuela originally and since you mentioned other countries like Mozambique and also Ukraine, I can tell you the situation in Venezuela is very dire. Like, we don't have statistics. We know there is a group Save the Children where we have very fragmented statistics, but we know that children as eight or nine years old commit to die by suicide because they're hungry in the family and they say, I'd rather die so there's not an extra burden in the family. So that kind of situation, I'd like to hear your opinion of each one of you because that is entirely a different page, I think, for sure. And also another thing, you mentioned in the new program about cognitive behavior therapy for suicide. Maybe I came a few minutes later. I'm an expert in behavioral and cognitive therapy so I'd like to hear if there's something, some comments about that. Thank you very much. Thank you for that comment and we know that social determinants of health like food insecurity, housing insecurity, all of those things can increase risk for suicide and also increase risk for medical assistance in dying, it turns out, too. About the cognitive behavior for suicide prevention, that is an excellent intervention that was developed, again, at the University of Pennsylvania by Dr. Greg Brown and also shown to decrease suicidal behavior in individuals in the emergency room by about 40%. He published that in 2005 in JAMA. And the key issue is that, like all cognitive behavioral therapy, it takes several sessions, around 14, and delivering it with fidelity, which is what makes it work, is not trivial. And I would just add, in terms of the heartbreaking eight to nine-year-olds because one less mouth to feed, the more we get upstream with detection, we can identify that thought earlier and perhaps intervene, which is what I was talking about. Well, that intervention will involve addressing some of those social needs, so the social determinants of health is where we come right back to. And part of the thing is, which is why I also do the plug for the suicide safety plan and part of why I, when I was working with CMS to develop those quality measures of the suicide safety plan, became a key component to it, you do not need those specialized skills that's needed in providing cognitive behavioral therapy. So here's a brief intervention that could actually be used to kind of keep the person safe for a period of time. And one of the things, one piece that Dr. Kendall didn't mention in the suicide safety plan, which is helping the person identify their own coping skills. Because a lot of times, as you're speaking with patients, and you're going through the safety plan with them, and you ask them about situations in their lives and how did they handle those situations, and as they talk to you about it, and you say, well, that's a coping skill, and they had no clue that they had this coping skill in their tool belt. So kind of letting them become more aware of how they themselves can actually keep themselves safe, I find is really interesting. So just the fact that the suicide safety plan doesn't require those specialized skills, I think is really important. So people can be quickly trained. I think we're at time. Oh, we're at time, oh yeah. Oh dear, we're at time. So sorry, it's 9.30, and I at least have to go to another meeting. So thank you for your attention. Thank you.

suicide prevention

Diana Clark

epidemiologist

stigma

C-SSRS

Dr. Posner

universal screening

minorities

workforce suicides

safety planning intervention

telehealth

technology

systematic interventions