Addressing youth suicide: A matter of life and death

Transcript

• 00:00Good afternoon, everyone.
• 00:02May I have your attention,
• 00:04please?
• 00:05It is my great pleasure
• 00:07to have the honor of
• 00:09introducing Christine Cha. I'm honored
• 00:12in two regards.
• 00:13One,
• 00:14as a member of this
• 00:15department that I'm very, very
• 00:17happy she is a colleague
• 00:18in. Two, as a director
• 00:20of the Center for Brain
• 00:22and Mind Health that I'm
• 00:23very happy helped to recruit
• 00:25her. So Christine is a
• 00:26brand new phenotype,
• 00:27not just in our department,
• 00:29but at Yale,
• 00:30a joint recruit between the
• 00:31Child Study Center and the
• 00:33Center for Brain and Mind
• 00:33Health, which is oriented towards,
• 00:36using neuroscience to improve patient
• 00:38care.
• 00:40Christine embodies the ideals of
• 00:42both the department and the
• 00:43center. She is a clinician.
• 00:45She's a clinical psychologist by
• 00:46training, and her clinical work
• 00:48is focused on suicide
• 00:50and,
• 00:51self injury in youth. Her
• 00:53research
• 00:54is aligned with her clinical
• 00:55work.
• 00:56Her research is is really
• 00:58interesting in its,
• 01:01in how programmatic it is,
• 01:02how innovative it is, and
• 01:03how integrative it is. She
• 01:05studies assessment
• 01:07of suicidal behavior. She studies
• 01:09how to predict
• 01:10suicidal
• 01:11behavior, and then she studies
• 01:12how to intervene. And she
• 01:14does this using really a
• 01:15diversity of tools,
• 01:16you know, from parent questionnaires
• 01:18to neurofeedback,
• 01:19which I think is pretty
• 01:20cool and is
• 01:22really aligned with the way
• 01:23we do work here as
• 01:24well as in the center.
• 01:26Christine has, a stellar track
• 01:28record. She got her PhD
• 01:29from Harvard, did her residency
• 01:31as a at Brown.
• 01:32She
• 01:34she then,
• 01:36she accept accepted a faculty
• 01:37position right out at Columbia.
• 01:39We then recruited her here.
• 01:41We have to be careful
• 01:42because I think there's one
• 01:43or two Ivy League she
• 01:44hasn't yet worked at, so
• 01:46we may be at risk
• 01:47for losing her. She has
• 01:48received many accolades. I won't
• 01:50name them all. Among them,
• 01:51for those of you who
• 01:52are psychological researchers,
• 01:54she received the rising star
• 01:55award from APS, which is
• 01:56really one of the most
• 01:57prestigious awards that someone could
• 01:59get early in their career
• 02:00and is so well deserved.
• 02:02She,
• 02:03many of you may collaborate
• 02:04with her already, and she's
• 02:06only been here a short
• 02:07period of time. She is
• 02:08an extremely
• 02:09enthusiastic
• 02:10there are a few times
• 02:11when one can use the
• 02:12word promiscuous and has a
• 02:13positive connotation. She is a
• 02:14promiscuous
• 02:15collaborator,
• 02:16and that is outstanding.
• 02:18And I feel like if
• 02:19I'm gonna time when to
• 02:20actually get her at the
• 02:21podium based on embarrassment,
• 02:22right now.
• 02:30Thank you so much. Thank
• 02:31you, Jamie, and thank you
• 02:33everyone for for being here
• 02:34and for tuning in.
• 02:37So hopefully my slides behave.
• 02:40Okay.
• 02:41So as Jamie mentioned,
• 02:43I am relatively new to
• 02:44Yale. I started in September.
• 02:46And I thought I would
• 02:47just share a few things
• 02:48about myself,
• 02:49on a personal note,
• 02:51just to say that while
• 02:52I'm new to Yale, I'm
• 02:53not entirely new to New
• 02:53Haven,
• 02:56having been born and raised
• 02:56in Connecticut and New Haven
• 02:58County. So on some level,
• 03:00it's nice to come home.
• 03:02And
• 03:03Jane already mentioned this. I'm
• 03:04a clinical psychologist by training,
• 03:07and I'm really proud to
• 03:08have been hired through a
• 03:09partnership between the Center for
• 03:10Brain and Mind Health and
• 03:11the Child Study Center here.
• 03:14And I've conducted research on
• 03:15youth suicide risk, and prevention
• 03:17both in and out of
• 03:18hospital settings,
• 03:20for about twenty years.
• 03:21And one thing I'll mention
• 03:23at the outset,
• 03:24given the topic that we're
• 03:25gonna be talking about today,
• 03:27is just kind of the
• 03:28lens with which I,
• 03:30I approach this work.
• 03:32So kind of on a
• 03:33personal professional note, I consider
• 03:35myself to be a constructive
• 03:37optimist.
• 03:38And it's you know, while
• 03:40we're gonna be,
• 03:41kind of grappling with this
• 03:42challenging topic of suicide,
• 03:44it's accompanied with the hopeful
• 03:46progress, that we're making to
• 03:48address this public health concern.
• 03:52So to provide some context,
• 03:54my work in youth suicide
• 03:55research has led to,
• 03:57over five hundred encounters with
• 03:59at risk individuals
• 04:00across the lifespan.
• 04:02And so these encounters,
• 04:04have ranged from talking to
• 04:05a fifteen year old who
• 04:07are who's openly disclosing their
• 04:09suicidal thoughts for the first
• 04:10time in their life to
• 04:11somebody on the phone,
• 04:13to meeting with a teenager
• 04:15while they're in the inpatient
• 04:16unit following a recent suicide
• 04:18attempt, to speaking with someone
• 04:20who is an active and
• 04:21acute crisis during in the
• 04:22midst of a conversation,
• 04:24and to bring front and
• 04:26center, what these moments feel
• 04:28like. Obviously,
• 04:29these these moments can feel,
• 04:32our experience in unique ways.
• 04:34But to focus on one
• 04:36particular,
• 04:38individual,
• 04:39I spoke with a young
• 04:40gentleman who recently described his
• 04:42lowest of lows
• 04:44as a feeling that he
• 04:45gets in his chest, where
• 04:46everything is loud and chaotic
• 04:48and it can feel like
• 04:49being caught in a storm
• 04:50with no cover.
• 04:51And this particular teenager,
• 04:53being an artist,
• 04:55created and shared this image
• 04:56conveying his experience with me
• 04:58in my lab.
• 05:01And he's not the only
• 05:02one, as many of you
• 05:03know.
• 05:04Approximately one in five youth
• 05:05around the world experience suicidal
• 05:07thoughts,
• 05:08and the thoughts of hurting
• 05:09themselves as well as ending
• 05:11their life.
• 05:12And these types of thoughts
• 05:13and feelings emerge commonly and
• 05:15rapidly,
• 05:16throughout adolescence, highlighted in yellow
• 05:18on,
• 05:19where you see this rapid
• 05:21rise in first time instances
• 05:23of experiencing suicidal thoughts shown
• 05:25on the left hand side,
• 05:26as well as on the
• 05:26right hand side, a steep
• 05:28rise in suicide death rates
• 05:29between the age of ten
• 05:31to twenty years.
• 05:33Concerns are further amplified when
• 05:35observing suicide death rates in
• 05:37the context of other injury
• 05:38related,
• 05:39deaths over time. So take
• 05:41Connecticut, for example, when we
• 05:43observe rates of death by
• 05:44motor vehicle suicide and homicide
• 05:47over the past, several decades,
• 05:49where in recent years,
• 05:51we see suicide shown in
• 05:53light green emerging as the
• 05:54leading cause of injury related
• 05:56death in the state of
• 05:57Connecticut,
• 05:57and this being indicative of
• 05:59trends across the country as
• 06:00well.
• 06:02And suicide remains the second
• 06:04leading cause of death among
• 06:05adolescents and young adults, both
• 06:07in Connecticut and in the
• 06:08US.
• 06:09And so at both a
• 06:10local and a national level,
• 06:12there's clearly an urgent need
• 06:13to address this public health
• 06:15concern.
• 06:17Now to add further context,
• 06:19I thought I'd provide a
• 06:20quick snapshot
• 06:21of prior research efforts to
• 06:23address suicide.
• 06:26Starting with this question of
• 06:27prediction, which helps us determine
• 06:29who will consider
• 06:30attempt or die by suicide
• 06:32in the future.
• 06:33So what we know based
• 06:34on the past fifty years
• 06:36of longitudinal studies of suicide
• 06:37risk factors,
• 06:39is that these studies have
• 06:40primarily focused on demographic risk
• 06:42factors along with a limited
• 06:44repertoire of psychiatric and social
• 06:46risk factors, broadly listed here.
• 06:49A now well known meta
• 06:50analysis delivered sobering news several
• 06:52years ago,
• 06:54showing that we have not
• 06:55really gotten better and, in
• 06:56fact, arguably worse at predicting
• 06:58suicide related outcomes using such
• 07:00risk factors.
• 07:03Turning to the topic of
• 07:05treating and reducing suicide related
• 07:07outcomes. Through a separate meta
• 07:08analysis, my colleagues and I
• 07:10found a nearly exponential
• 07:12increase in the number of
• 07:13treatments for suicidal patients tested
• 07:15over the past fifty years.
• 07:17However,
• 07:18we also found that treatment
• 07:20effects remained modest at best,
• 07:22with treatment effects alarmingly weaker
• 07:24among children and adolescents compared
• 07:26to older populations.
• 07:28And so while there have
• 07:29been many noteworthy,
• 07:31approaches to addressing the problem
• 07:33of suicide, there's an urgent
• 07:34need to do better and
• 07:36to approach the problem of
• 07:37suicide in new ways.
• 07:40And so,
• 07:41my lab and,
• 07:43collaborative network here, at Yale
• 07:45are striving to do that
• 07:47in three ways
• 07:48by leveraging multiple data streams
• 07:50to help explain three things.
• 07:52First, who is at risk
• 07:54of hurting themselves?
• 07:56Second, why young people might
• 07:58consider suicide?
• 07:59And third, now what do
• 08:00we do to help reduce
• 08:02future suicide risk?
• 08:04And so starting with the
• 08:05first line of work I've
• 08:06pursued in the lab,
• 08:08I'll start with the ideal
• 08:09scenario
• 08:10that, ideally, we would have
• 08:12the tools to help inform
• 08:13clinical decision making in order
• 08:15to systematically identify
• 08:17which youth may be most
• 08:18likely to kill themselves,
• 08:20like this,
• 08:21so that clinicians know where
• 08:22to direct their attention and
• 08:24intervention efforts.
• 08:26Now, unfortunately,
• 08:28as many of you who
• 08:28have been exposed to hospital
• 08:30or psychiatric settings, may know,
• 08:32the reality of everyday risk
• 08:34assessment can look somewhat less
• 08:36orderly,
• 08:37and straightforward,
• 08:38and instead more like this.
• 08:41A busy place with limited
• 08:43time, space, and tools to
• 08:45make this high stakes decision,
• 08:47where oftentimes clinician may ask
• 08:49a question such as the
• 08:50following to assess suicide risk.
• 08:52So from the CSSRS,
• 08:54have you ever wished you
• 08:54were dead or wished you
• 08:55could go to sleep and
• 08:56not wake up?
• 08:58And then primarily relying on
• 08:59patient self report at times
• 09:01resulting in situations where a
• 09:03patient may say, for instance,
• 09:05no. I'm fine,
• 09:07which may or may not
• 09:08be aligned with their internal
• 09:09thoughts and emotions.
• 09:11Indeed, the main way in
• 09:12which we determine who is
• 09:13at risk is to ask,
• 09:16pointing to a heavy reliance
• 09:17on self report.
• 09:19Now I'm not suggesting to
• 09:21never ask a patient how
• 09:22they're doing. Of course, it's
• 09:24a given that we directly
• 09:25ask our patients and engage
• 09:26with,
• 09:27them around their subjective experience.
• 09:30But at the same time,
• 09:32we know that there are
• 09:33challenges to solely relying on
• 09:35self report, even in those
• 09:37children and adolescents engaged in
• 09:38treatment
• 09:39who don't disclose, their suicidal
• 09:42thoughts to their therapist.
• 09:43And we also see that
• 09:44self report assessments of suicide
• 09:46risk has its limitations across
• 09:47multiple settings, including at home
• 09:50and at school, with teachers
• 09:51and parents oftentimes underreporting the
• 09:54severity or extent of their
• 09:56suicidal of what the youth
• 09:57are experiencing.
• 09:59And we found, in a
• 10:01recent study led by my
• 10:02doctoral student Paige Spears,
• 10:04that one in four suicidal
• 10:06youth never disclose their engagement
• 10:08to anyone, including their most
• 10:09trusted personal confidants.
• 10:13So, to address this challenge,
• 10:15my lab has tested alternative
• 10:17suicide risk tools that do
• 10:19not rely solely on self
• 10:20report and instead rely on
• 10:22behavioral markers.
• 10:24As an example of this,
• 10:25we've tested patients' reaction times
• 10:27on the death implicit association
• 10:29test, a brief computerized word
• 10:31sorting task that examines how
• 10:32strongly they pair different concepts
• 10:35such as death and me
• 10:36to examine the degree of
• 10:37implicit identification
• 10:39with death.
• 10:41And so in the death
• 10:42IAT,
• 10:43patients view paired concepts,
• 10:45on the screen and are
• 10:46asked to sort words or
• 10:48pictures,
• 10:49as into the correct categories
• 10:50as fast and as accurately
• 10:52as they can.
• 10:53And the idea about this
• 10:54and the way it's designed
• 10:55is that suicidal patients would
• 10:57be expected to more quickly
• 10:58respond to the task during
• 11:00blocks of trials where death
• 11:01and me are paired together,
• 11:04compared to when life and
• 11:05me are paired together.
• 11:08And this seminal and now
• 11:10well replicated adult based work
• 11:11on the deaf IAT,
• 11:14came from, my doctoral advisor,
• 11:16Matt Nock.
• 11:17And one question as I
• 11:19was seeing Matt in grad
• 11:20school do this work that
• 11:21came to mind for me,
• 11:23was realizing that we do
• 11:26see and encounter suicidal or
• 11:27at risk patients and multiple
• 11:29levels of care.
• 11:31And it's this question of
• 11:32whether,
• 11:33a brief measure,
• 11:35such as the death IET
• 11:37delivered in an emergency room
• 11:38would have the same predictive
• 11:40validity
• 11:40as when delivered, let's say,
• 11:42in a much more neutral
• 11:43setting.
• 11:45And so my thinking around
• 11:47this was guided by John
• 11:48Teasdale's differential activation hypothesis,
• 11:51proposing that negative mood can
• 11:53activate maladaptive cognitive processes,
• 11:56begging this question of whether
• 11:57cognitive bias detected,
• 12:00by the death IAT would
• 12:01be more readily detectable in
• 12:03an activated
• 12:04negative mood state and more
• 12:05predictive of suicide related outcomes
• 12:07over time.
• 12:10And so this was in
• 12:11a sample of adults. We
• 12:13set out to test this
• 12:14idea in a collaboration with,
• 12:16Rory O'Connor at the University
• 12:17of Glasgow. We recruited two
• 12:19hundred and sixty four suicidal
• 12:20and non suicidal adults from
• 12:22both Boston and Glasgow, Scotland.
• 12:24And so these participants came
• 12:26into the lab, completed the
• 12:27death IAT before and after
• 12:29a brief negative mood induction.
• 12:31This was a ten minute
• 12:32Velton mood induction,
• 12:33which induced more of a
• 12:34negative
• 12:35negative valence low,
• 12:38arousal,
• 12:39mood state.
• 12:40I should also,
• 12:41mention we very actively,
• 12:44observed them during, the process
• 12:46of the negative mood induction,
• 12:48looked, and tracked mood recovery,
• 12:50and then also had safety
• 12:52procedures, resources, and a positive
• 12:54mood induction, as well as
• 12:55a debriefing at the conclusion
• 12:57of their visit.
• 13:00And so we wanted to
• 13:01see, whether or not, again,
• 13:04really compare their IAT scores
• 13:06before and after this negative
• 13:07mood induction.
• 13:09And so here, I'll show
• 13:10you, the pre and post
• 13:11induction performance
• 13:13with non ideators in light
• 13:14bars and suicide ideators in
• 13:16dark bars.
• 13:17And the higher IAT d
• 13:18scores indicate stronger identification with
• 13:20death.
• 13:21And so as you can
• 13:22see, pre induction performance yielded
• 13:25the expected pattern with suicide
• 13:27ideators in dark bars having
• 13:29that higher score than non
• 13:30ideators.
• 13:31And the group difference was
• 13:32significantly larger when the IIT
• 13:34was completed in a negative
• 13:35affective state.
• 13:37And as you can see,
• 13:38this was largely driven by
• 13:39an increase in pre to
• 13:41post performance among suicide ideators
• 13:44versus the non ideators.
• 13:46Building on these cross sectional
• 13:48analyses,
• 13:49we went on to find
• 13:50that it was only the
• 13:51post induction IT performance that
• 13:53predicted suicidal ideation six months
• 13:55later above and beyond prior
• 13:57history of ideation.
• 13:59And this for me really
• 14:01informed the potential clinical, implications
• 14:03of the death IAT,
• 14:05and the potential moderating effect
• 14:07of respondent affective state
• 14:09where we may want to,
• 14:11interpret risk assessment such as
• 14:13this, very differently in a
• 14:14more routine outpatient setting compared
• 14:17to a high intensity acute
• 14:18and potentially stressful,
• 14:20emergency department within hours of
• 14:22a suicide related crisis.
• 14:25And so what we did,
• 14:27was bring, the death IAT,
• 14:30to a younger, more more
• 14:31acute sample.
• 14:33And this was the youngest
• 14:34and most, diverse,
• 14:36sample of adolescent psychiatric,
• 14:39youth we could really find.
• 14:41And we administered the death
• 14:43IAT, those who had had
• 14:44medical clearance in order to
• 14:45be approached by our research
• 14:47team,
• 14:48and administered the death IAT
• 14:49to a hundred and sixty
• 14:50seven acutely suicidal preteens and
• 14:52teens presenting to the Bellevue
• 14:54child psychiatric emergency room.
• 14:56And what we found was
• 14:57that their death IET scores
• 14:59predicted which among these youth
• 15:01proceeded to attempt suicide six
• 15:03months later, being able to,
• 15:04in fact, distinguish who thinks
• 15:06about suicide
• 15:07from who thinks about and
• 15:09proceeds to act on those
• 15:10suicidal thoughts.
• 15:14And so when,
• 15:16pursuing this work, you may
• 15:17also be wondering, apart from
• 15:19its potential clinical utility and
• 15:21efficiency as a quick task,
• 15:23what exactly do patients see
• 15:25when completing the death IAT?
• 15:28And I don't wanna take
• 15:29for granted,
• 15:30that this reaction time task
• 15:32involves rapidly presenting words and
• 15:34sometimes images related to suicide,
• 15:36death, and self harm.
• 15:38And I should say that
• 15:39this wasn't in response to
• 15:41complaints that we were getting
• 15:42or feedback,
• 15:43that we were getting from
• 15:44our participants, but just from
• 15:46our own observation,
• 15:48and and just being able
• 15:50to to sleep a little
• 15:51bit better at night, really
• 15:52checking our assumptions as to
• 15:54whether or not this is
• 15:55an appropriate measure to be
• 15:57delivering.
• 15:58So we asked, young respondents,
• 16:00in one of our studies
• 16:01immediately before and after taking,
• 16:03the IAT about their current
• 16:05mood, their current desire to
• 16:07hurt themselves, and their desire
• 16:08to die.
• 16:10What we found was no
• 16:11significant change in mood. This
• 16:13was among,
• 16:14suicidal adolescent inpatients.
• 16:17No significant change in desire
• 16:19to hurt themselves.
• 16:21And essentially, based on the
• 16:22small effect size, no change
• 16:24in desire to die. I
• 16:25won't go ahead and make
• 16:26claims that we're making people
• 16:28less likely to, to want
• 16:30to die, although that's, that's
• 16:32what the the pattern seems
• 16:33to be suggesting, but essentially
• 16:35a flat line indicating no
• 16:36change.
• 16:39And we saw this replicated,
• 16:41in terms of patterns of
• 16:42desire to self injure and
• 16:43desire to die across several
• 16:45other samples, including web based
• 16:47adult respondents as well as
• 16:49college
• 16:50students.
• 16:51And then going back to
• 16:52the Bellevue ED,
• 16:54when we administered these same
• 16:55measures, we found no significant
• 16:57mean
• 16:58we we saw no change
• 16:59in mood.
• 17:00I'm sorry. A significant,
• 17:02improvement in mood, as well
• 17:04as a decline in desire
• 17:06to die and desire to
• 17:07kill oneself. But again, these
• 17:08are relatively modest effects. So
• 17:10we're not suggesting a therapeutic
• 17:11effect of the measure.
• 17:14One thing I do wanna
• 17:15point out is that we
• 17:16did observe a mood change
• 17:17as a function of gender.
• 17:19And so you see the
• 17:20female respondents here in the
• 17:22red lines actually,
• 17:23demonstrating,
• 17:24a mood decline compared to
• 17:26male respondents in blue.
• 17:28And something to note when
• 17:30interpreting these figures is at
• 17:31the bottom,
• 17:33the zero or the five
• 17:35at the bottom,
• 17:36at, of the y axis
• 17:38indicates neutral mode. So this
• 17:40was a case of female
• 17:42respondents going from more positive
• 17:44mood to less positive mood,
• 17:46not crossing over into negative
• 17:48mood.
• 17:50Continuing this line of research,
• 17:52my lab is continuing to
• 17:53explore new domains to detect
• 17:55suicide risk.
• 17:56So to do so, I
• 17:58actually bring you back, to
• 17:59the traditional form of assessing
• 18:01risk
• 18:02where a clinician prompts for
• 18:04self reported response from the
• 18:06patient.
• 18:07But this time, my brilliant
• 18:08doctoral student, Ilana Gratch,
• 18:11through an f thirty one
• 18:12supported collaboration with Jeff Cohen,
• 18:14has examined not what people
• 18:16say, but instead their behavior
• 18:18when they respond,
• 18:19specifically
• 18:21through their facial actions, which
• 18:22are microexpressions
• 18:23on people's faces.
• 18:25And with the sample of
• 18:26young adults, we recently found
• 18:28that certain facial expressions of
• 18:30interviewees,
• 18:33in combined with the facial
• 18:35expressions of their interviewers,
• 18:37accurately classified,
• 18:39suicidal from nonsuicidal
• 18:41young adult respondents.
• 18:43And in fact,
• 18:45what was really surprising to
• 18:46us was actually the facial
• 18:48actions of the interviewers.
• 18:50So our research staff actually,
• 18:52that seemed to predict,
• 18:54those
• 18:56suicidal young adults who who
• 18:58went on to actually engage
• 19:00in suicidal behaviors three months
• 19:02later.
• 19:03These were preparatory actions,
• 19:05aborted or interrupted suicide attempts
• 19:07or suicide attempts.
• 19:10And so in terms of
• 19:11next steps,
• 19:13here at Yale, we're really
• 19:14excited to move in the
• 19:16direction of bringing together these
• 19:18different data streams in accurate,
• 19:20interpretable, and user friendly ways,
• 19:23to really bring it back
• 19:24to the health care provider,
• 19:26to social workers, nurses,
• 19:28physicians, psychologists,
• 19:30who are working with at
• 19:31risk youth and engaging
• 19:33in these high stakes clinical
• 19:34decisions.
• 19:35And doing this obviously requires
• 19:37a team science approach, which
• 19:39is why I'm especially grateful
• 19:40to be here,
• 19:42at Yale and,
• 19:44through the the Center for
• 19:45Brain and Mind Health facilitating
• 19:46these cross disciplinary,
• 19:48collaborations.
• 19:50Continuing this line of research,
• 19:52my lab is exploring,
• 19:54additional
• 19:56questions around detecting risk,
• 19:59by actually going,
• 20:00to,
• 20:02earlier developmental periods.
• 20:04And, I mentioned earlier that
• 20:07there does remain tremendous value
• 20:08still to patient self report.
• 20:11And this important line of
• 20:12work, is being led by
• 20:14my doctoral student, Nathan Lowry,
• 20:16who has an interest in
• 20:17seeing how common universal screening
• 20:19measures such as the ASK,
• 20:21ASQ or CSSRS
• 20:23may be adapted,
• 20:24when suicide screening,
• 20:26occurs in children or preteens
• 20:29ranging in age from eight
• 20:30to eleven years old.
• 20:32And what has been I
• 20:33know this sounds like a
• 20:34very young age group, but
• 20:36what's been motivating our lab's
• 20:37attention toward this age group
• 20:38has been the alarming rise
• 20:40of suicide death rates detected
• 20:42over the past,
• 20:43I want to say decade,
• 20:45probably more than that,
• 20:47among eight to eleven year
• 20:49olds in this country.
• 20:50And so,
• 20:52Nathan is leading a
• 20:54investigation,
• 20:55really examining these foundational questions
• 20:58that can help shape a
• 20:59more developmentally sensitive approach to
• 21:01asking children about suicide, adapting
• 21:04vignettes from developmental psychology
• 21:06designed to gauge children's understanding
• 21:08of continued biological or psychological
• 21:11functioning after death, with some
• 21:13sample statements for youth evaluated
• 21:15here.
• 21:18So beyond developing,
• 21:20methods to identify patients at
• 21:21elevated risk, another line of
• 21:23our research explores possible explanations
• 21:26for why exactly young people
• 21:28may consider suicide.
• 21:30One of the first things
• 21:31that may come to mind,
• 21:33at least for me, is
• 21:34a strong desire for death
• 21:36and association associated death oriented
• 21:39cognitions.
• 21:41And so my former trainee,
• 21:43Catherine Tizanos,
• 21:44who's now on faculty at
• 21:45Brown,
• 21:46examined a foundational question on
• 21:48how adolescents view and orient
• 21:50themselves toward death.
• 21:52Do they engage in death
• 21:54avoidance where they avoid the
• 21:55thoughts of death at all
• 21:57costs
• 21:58or neutral acceptance in viewing
• 22:00death as simply a part
• 22:01or process of life?
• 22:04Or finally, do they view
• 22:05death as an appropriate escape
• 22:07from pain and suffering, otherwise
• 22:09known as escape acceptance?
• 22:12And first, in the sample
• 22:13of seventy four community based
• 22:15adolescents, we found that, not
• 22:17surprisingly, those with a history
• 22:18of suicidal ideation tended to
• 22:20avoid the thoughts of death,
• 22:22significantly less,
• 22:25compared to, those without,
• 22:27such history.
• 22:30And then there was really
• 22:32not a difference in how
• 22:33they viewed,
• 22:34death as a natural part
• 22:36of life.
• 22:37And then the most robust
• 22:38pattern really emerged in the
• 22:40case of escape acceptance,
• 22:42such that suicidal adolescents view
• 22:44death as an acceptable form
• 22:45of escape from pain and
• 22:46suffering,
• 22:48and stronger levels of escape
• 22:49acceptance at baseline predicted greater
• 22:52likelihood of suicidal ideation six
• 22:54months later.
• 22:56Now given that these data
• 22:58were initially collected in a
• 23:00community based,
• 23:01setting,
• 23:02outside the hospital, you may
• 23:04be wondering,
• 23:05whether similar patterns would emerge
• 23:07in a more clinically severe
• 23:08sample.
• 23:09So to provide a point
• 23:10of comparison,
• 23:13when we brought the same
• 23:14measure, into the Bellevue emergency
• 23:16room,
• 23:18I show here the same
• 23:20ratings,
• 23:21of those,
• 23:22preteens and teens, who had
• 23:24recently experienced a suicide related
• 23:26crisis and were coming to
• 23:27the Bellevue ED.
• 23:29And you can see stark
• 23:31differences, especially when it comes
• 23:32to escape acceptance.
• 23:34And this tracks with recent
• 23:35findings in adults reporting motivations
• 23:37to attempt suicide to escape
• 23:39from psychologically
• 23:40aversive conditions after concluding
• 23:43that no other effective solution
• 23:44or strategy was available.
• 23:50Now pausing here,
• 23:52I've spent a good portion
• 23:54of time focusing,
• 23:56and referring to death,
• 23:58fixating on what motivates people
• 24:00toward an openness or desire
• 24:01to kill themselves.
• 24:04But this isn't the full
• 24:06picture, since suicidal individuals experience
• 24:09is not solely defined by
• 24:10a desire to kill themselves.
• 24:13They may not necessarily reject
• 24:14this notion of life in
• 24:16an alternative path,
• 24:18other than one that leads
• 24:19to suicide.
• 24:21And one way I I
• 24:22like to think about this
• 24:23is,
• 24:25while it's not the case
• 24:26for all, suicidal adolescents,
• 24:28a fifteen year old who
• 24:29might be struggling with suicidal
• 24:31thoughts may be getting out
• 24:32of bed, and the first
• 24:33thought they have is that
• 24:34they wanna kill themselves. But
• 24:36it might also be mixed
• 24:37in with thoughts of what
• 24:38type of socks they're gonna
• 24:40put on their feet and
• 24:41what they're gonna have for
• 24:42breakfast and whether they're going
• 24:43to make the school bus
• 24:44on time.
• 24:45And those don't refer to
• 24:47death and don't refer to
• 24:48a desire to die. They're
• 24:50referring to those
• 24:51mundane but important next steps
• 24:53that keep them going forward.
• 24:56And this general notion of
• 24:58an internal debate between death
• 25:00and life has been considered
• 25:02for decades,
• 25:03with, for instance,
• 25:05intermedial
• 25:07states characterized by, as he
• 25:09says, a vitality of consciousness
• 25:11ranging between cessation and ardent
• 25:13living.
• 25:14And Kovacs and Beck, emphasizing
• 25:16an internal subjective struggle between
• 25:18a wish to die and
• 25:19a wish to live, which
• 25:20serves as this powerful reminder
• 25:22to not discount the wish
• 25:23to live when studying suicidal
• 25:25individuals.
• 25:28And so tied to this,
• 25:29my lab in collaboration with
• 25:30Dan Schachter,
• 25:31cognitive psychologist,
• 25:33and Don Rabenau,
• 25:35we've used these cognitive measures
• 25:37developed and tested in Dan's
• 25:38lab to capture how suicidal
• 25:40individuals
• 25:41view the continuation of their
• 25:43lives.
• 25:44Meaning, when people are asked
• 25:45to imagine what they may
• 25:46do in life, let's say
• 25:48within the next hour or
• 25:49the next day or week
• 25:51or year,
• 25:52what comes to mind?
• 25:54Can they generate a clear
• 25:56and mentally tangible image of
• 25:57the future in their minds,
• 25:59or do they have a
• 26:00more difficult time generating any
• 26:02notion of the future at
• 26:03all?
• 26:05And there's been past references
• 26:06to this,
• 26:07idea,
• 26:08in the field as well.
• 26:10Some work in the early
• 26:11seventies with studies observing suicidal
• 26:13patients using future,
• 26:15tense verbs less frequently,
• 26:17and having limited future time
• 26:19perspective.
• 26:20And then a bit in
• 26:21the nineties with, Roy Baumeister
• 26:23and his escape theory,
• 26:25proposing limited time perspective
• 26:27and the absence of distal
• 26:28goals among suicidal individuals.
• 26:31And then an acknowledgment by
• 26:32prominent clinical psychologist,
• 26:34Mark Williams,
• 26:35emphasizing,
• 26:36the potential promise of studying
• 26:38future thinking,
• 26:40saying that the clinical context
• 26:41in which perspective on the
• 26:43future is the most central
• 26:44element is suicidal depression.
• 26:47Now in terms of how,
• 26:49future thinking is captured,
• 26:51I'll go into this in
• 26:52a moment and wanna walk
• 26:54you through a study that
• 26:55we recently completed and published
• 26:57on community based, adolescents,
• 27:00a portion of of whom
• 27:01had history of suicidal thoughts.
• 27:04And so we examined episodic
• 27:06future thinking,
• 27:07in the lab through a
• 27:08behavioral paradigm. I'll show you
• 27:09in a moment,
• 27:11along with the control task
• 27:12to capture,
• 27:14narrative style, which I'm happy
• 27:15to elaborate on if folks
• 27:16are curious.
• 27:18And so after they came
• 27:19into the they were screened,
• 27:21they came into the lab,
• 27:22completed the task.
• 27:23We let them go and,
• 27:25had them complete online surveys,
• 27:27indicating
• 27:28their degree of suicidal thoughts,
• 27:30three and six months later.
• 27:33Now focusing on this measure
• 27:35of future thinking.
• 27:38So the ERT experimental recombination
• 27:40task from Dan Schachter's lab
• 27:42is a behavioral paradigm that
• 27:44essentially prompts a person to
• 27:46focus on a single event
• 27:47localized in time and space
• 27:49and elaborate on that event
• 27:51with the prompt being something
• 27:53like, for the next three
• 27:54minutes, imagine blank. You're given
• 27:56some cues and describe it
• 27:57in as much detail as
• 27:59you can, what you'll be
• 28:00doing, thinking,
• 28:01hearing, seeing, feeling, etcetera. Really
• 28:03trying to bring that image,
• 28:05internal image of the future
• 28:07to life.
• 28:09And so in this example,
• 28:11maybe a team would be
• 28:12presented with the cues, personalized
• 28:14cues. So imagine a positive
• 28:15event in the next five
• 28:17years involving
• 28:18your cousin, the Strand Bookstore,
• 28:21as well as a phone,
• 28:22an object. So person, place,
• 28:23object, cue.
• 28:26And these would have been,
• 28:27kind of pre,
• 28:29pre collected.
• 28:30And so to measure the
• 28:31level of detail, we audio
• 28:32recorded and parsed participants event
• 28:35descriptions into individual components
• 28:37with blinded coders then categorizing
• 28:39these components into either internal
• 28:41or external details.
• 28:43Fortunately, we have natural language
• 28:45processing that helps,
• 28:47expedite this process now, but
• 28:48there were many years dedicated
• 28:50to the manual coding of
• 28:51this.
• 28:53Internal details,
• 28:54or IDs
• 28:55are those that are relevant
• 28:57to the central event,
• 28:58such as I will pick
• 28:59up my I will pick
• 29:01up my phone to call
• 29:02my cousin or my cousin
• 29:03and I will plan to
• 29:04meet at the strand tonight.
• 29:06So discrete actions that could
• 29:08plausibly happen in the imagined
• 29:09future event.
• 29:11External details could be semantic
• 29:13like statements that are relevant
• 29:15but not actually fixed in
• 29:16the imagined event, such as
• 29:18the strand is a huge
• 29:19bookstore, or my cousin loves
• 29:20the strand.
• 29:22So we might expect that
• 29:24suicidal adolescents attempt to when
• 29:26they're attempting to describe their
• 29:28future, a more vague over
• 29:29generalized picture may emerge,
• 29:31such that they're, resulting in
• 29:33a lower internal detail count.
• 29:37So focusing
• 29:38on internal details at baseline,
• 29:41our suicidal adolescents shown in
• 29:43dark bars here. So they
• 29:44had experienced ideation,
• 29:46at least once in the
• 29:47past year, had imagined fewer
• 29:49number of actions enacted in
• 29:51the future,
• 29:52specifically when imagining positive events
• 29:54compared to non suicidal adolescents
• 29:56shown in light bars.
• 29:58And future thinking abilities,
• 30:00appear to be protective of
• 30:01future risk such that better
• 30:03ability to imagine future actions
• 30:05regardless of valence
• 30:07predicted, those adolescents who would
• 30:09be less likely to experience
• 30:11suicidal ideation six months later.
• 30:14Something worth noting is that
• 30:15when we took the same
• 30:16ERT measure to the emergency
• 30:18room,
• 30:19in a recently published paper,
• 30:21led by my mentee, Olivia
• 30:22Pollock, we recently found a
• 30:24profound dampened ability shown in
• 30:26the blue dotted line in
• 30:27acutely suicidal youth in their
• 30:29ability to imagine future actions.
• 30:31Now you might be wondering
• 30:32why look at this basic
• 30:34cognitive ability in such a
• 30:36clinically acute environment.
• 30:38And one of the reasons
• 30:40why, I'm sure many of
• 30:41you are familiar with safety
• 30:43planning as a common,
• 30:45brief intervention that's delivered. And,
• 30:49if you think about kind
• 30:50of the the mechanics of
• 30:52safety planning,
• 30:53a lot of it is
• 30:54planning ahead for the future,
• 30:55anticipating,
• 30:57the next crisis to be
• 30:58able to create a cope
• 30:59ahead plan. And and imagine
• 31:01in your mind, you know,
• 31:02how likely it is that
• 31:04x coping strategy would be
• 31:06helpful or y coping strategy
• 31:07would be helpful.
• 31:11And then turning to other
• 31:12data streams, with a team
• 31:14of clinical psychologists and cognitive
• 31:16neuroscientists from the Laureate Institute
• 31:18for Brain Research,
• 31:20we recently found clinically meaningful
• 31:22differences in neural activity associated
• 31:24with future thinking. And this
• 31:25was in,
• 31:26the entire sample was, adult
• 31:28depressed patients,
• 31:30some of whom had history
• 31:31of suicidal thoughts and behaviors
• 31:33and some of whom had
• 31:34no history of suicidal thoughts
• 31:36and behaviors but did have
• 31:37depression.
• 31:38And so we saw among
• 31:39those depressed patients with a
• 31:41history of suicidal thoughts and
• 31:42behaviors,
• 31:44observing a blunted activation of
• 31:45the ventral medial prefrontal cortex
• 31:47relative to the non suicidal
• 31:48depressed control group,
• 31:50hinting at the possibility of
• 31:51a neural intervention target.
• 31:55So regarding next steps, pulling
• 31:57this together,
• 31:58my research is now beginning
• 31:59to pursue real time assessment
• 32:01of death and life oriented
• 32:03cognitions.
• 32:04One thing that we know
• 32:05about suicidal thoughts is that
• 32:07they are transient in nature.
• 32:09And that a person, even
• 32:11when struggling with severe suicidal
• 32:13thoughts, may not always want
• 32:15to die. And a main
• 32:16fact, again, like I said
• 32:17before, experience some ambivalence,
• 32:20termed this internal subjective struggle
• 32:22between life and death.
• 32:24But that capturing that internal
• 32:26subjective struggle can be hard
• 32:26relying on retrospective recall that
• 32:39capture these daily fluctuations with
• 32:41greater temporal granularity,
• 32:42we asked teens several times
• 32:44a day
• 32:45about their ongoing thoughts and
• 32:46feelings toward death and life
• 32:48as they go about their
• 32:49everyday lives.
• 32:50This was in, with parent
• 32:52consent, and then outside of
• 32:54school settings,
• 32:55delivered through a HIPAA compliant
• 32:57data collection app with parent,
• 32:58again, parent consent.
• 33:00And so this methodological approach
• 33:02known as ecological momentary assessment,
• 33:05was,
• 33:07administered in across a span
• 33:09of fourteen days,
• 33:10where adolescents were completing this
• 33:12as they were going about
• 33:12their every day. We had
• 33:14our team that was checking
• 33:15manually, and we also had
• 33:17an automated checking system to
• 33:19be gauging the level of
• 33:21suicidality,
• 33:22that was being endorsed. And,
• 33:24of course, clinicians like myself
• 33:25were on call to be
• 33:27intervening,
• 33:28checking in on youth as
• 33:29needed.
• 33:31And so we are actually
• 33:33wrapping up on this study,
• 33:35hopefully soon,
• 33:37with,
• 33:38my, former postdoc,
• 33:40and EMA expert, doctor Kayshen.
• 33:44And so far, our results
• 33:46are showing us
• 33:48that, for instance, when we
• 33:49are asking youth five times
• 33:51a day, are you thinking
• 33:52about the past, present, or
• 33:53future right now?
• 33:55Overall, they spend about one
• 33:57third of their time thinking
• 33:58about their future.
• 34:00And we find that these,
• 34:02moments when teens are experiencing
• 34:04suicidal ideation,
• 34:06there is a unique way
• 34:07in which they're viewing their
• 34:09future life.
• 34:10They perceive their future life
• 34:11to be negative and very
• 34:13far away, meaning not pertaining
• 34:15to the next few minutes
• 34:16or hours in the day,
• 34:17but instead the distant and
• 34:19potentially more abstract future.
• 34:21And they experience these thoughts
• 34:22as being intrusive and uncontrollable
• 34:24in nature.
• 34:27And building on this initial
• 34:28self report based methodology, we're
• 34:30expanding to not only what
• 34:31youth self report, but how
• 34:33they are reporting,
• 34:34by looking at facial,
• 34:36expressions as well as vocal
• 34:37features,
• 34:39as well as other biomarkers
• 34:40and digital markers that could
• 34:41be captured passively and in
• 34:43real time.
• 34:45With pilot work led by
• 34:46PGA,
• 34:47Maria Hansruth.
• 34:49I'm gonna embarrass Maria.
• 34:51Maria,
• 34:52has been doing, excellent work
• 34:53in taking a look at
• 34:54our pilot
• 34:55data, examining facial action data
• 34:57in suicidal young adults while
• 34:59they're imagining their future event.
• 35:01And specifically,
• 35:03we've been finding that,
• 35:04suicidal young adults compared to
• 35:06non suicidal display,
• 35:08action unit six and twelve,
• 35:10otherwise known as the Duchenne
• 35:11smile,
• 35:12for significantly fewer frames of
• 35:14the video recorded,
• 35:18future event description compared to
• 35:20nonsuicidal young adults. And this,
• 35:22seems specific to future thinking
• 35:24prompts because we're not seeing
• 35:26that same pattern come out,
• 35:27for instance, when they're engaging
• 35:28in different topics of conversation
• 35:30during that same visit.
• 35:34And this work I also
• 35:34wanna mention is in coordination
• 35:36with Ellen Lee.
• 35:37I'm gonna embarrass Ellen over
• 35:39there,
• 35:40and Shirley Wang who's in
• 35:42the psych department,
• 35:43just right down the road
• 35:44on College Street, who's launching
• 35:46her,
• 35:46real time multimodal assessment study
• 35:48this year, in suicidal young
• 35:50adults, with, us,
• 35:53launching with suicidal adolescents and
• 35:55their parents,
• 35:57in hopes to coordinate key
• 35:58parts of our data collection
• 35:59to facilitate data harmonization later
• 36:02on.
• 36:03And as Ellen,
• 36:04who is our apply applied
• 36:06AI expert can tell you,
• 36:08the reason and motivation for
• 36:10data harmonization
• 36:11is because work that would
• 36:13be leveraging deep learning models,
• 36:15which is really what this
• 36:16approach would demand,
• 36:18requires larger sample sizes.
• 36:23So one other exciting step
• 36:24that we're taking in why
• 36:26adolescents consider suicide is to
• 36:28summarize time series data,
• 36:30that we've been collecting in
• 36:32adolescents.
• 36:33And what I mean by
• 36:34this is taking intradaily
• 36:36time series data, which can
• 36:38be nuanced and not the
• 36:39easiest for anyone to interpret,
• 36:41and deliver it in a
• 36:42meaningful summary to youth, their
• 36:44families, and to their providers.
• 36:47This would be, for instance,
• 36:49this, these are EMA responses
• 36:51from a de identified patient,
• 36:53participant,
• 36:55where,
• 36:56you know, for instance, taking
• 36:57average responses from a single
• 36:59day of their EMA surveys,
• 37:01where,
• 37:02on their first day of
• 37:03the EMA survey, they reported
• 37:05a low to moderate wish
• 37:06to die shown in dark
• 37:09yellow,
• 37:09and a high wish to
• 37:11live shown in green.
• 37:13Day two, you start seeing
• 37:15a little bit of a
• 37:15concerning pattern,
• 37:17with a reduced wish to
• 37:18live and an increased wish
• 37:19to die.
• 37:21But then you continue following
• 37:23up, and you see this
• 37:24recovery that seems to sustain
• 37:26over time.
• 37:27And now while this information
• 37:29itself might be helpful in
• 37:31getting a sense of what,
• 37:32an a given adolescent's baseline
• 37:34might look like, there does
• 37:35remain this question of what
• 37:37accounts for some of these
• 37:38fluctuations.
• 37:39And so, we also capture,
• 37:41information around potential stressors,
• 37:43negative events, and positive events
• 37:45that they experience throughout the
• 37:46day. So for instance, we
• 37:48know from this particular teen,
• 37:50that on day two, when
• 37:51they had that decline,
• 37:53there were notable school stressors
• 37:54that they reported at the
• 37:56end of the day.
• 37:57And then picking day nine,
• 37:58which was one of the
• 37:59stronger,
• 38:00days, they,
• 38:02report, positive events such as
• 38:04receiving compliments.
• 38:07Now this idea
• 38:09of ambulatory
• 38:10assessment,
• 38:11is not limited to research
• 38:13studies.
• 38:14And in fact, our colleagues
• 38:15in cardiology offer nice examples
• 38:17of how this work has
• 38:18been put to work in
• 38:19clinical settings.
• 38:21And so some of you
• 38:22might be familiar with this
• 38:23example,
• 38:25but it just really struck
• 38:26me, recently,
• 38:28in,
• 38:29have folks heard of the
• 38:30Zio or or,
• 38:31observed the Zio before?
• 38:33So,
• 38:34just to kind of share
• 38:35this example of
• 38:37ambulatory assessment in action.
• 38:40So the Zio is a
• 38:41lightweight FDA approved portable ECG
• 38:44in the form of an
• 38:44adhesive patch monitor that's suitable
• 38:47for detecting cardiac arrhythmia,
• 38:50Where across seven to fourteen
• 38:52days, pretty comparable to the
• 38:54type of EMA responses we've
• 38:55been,
• 38:56collecting,
• 38:57a patient,
• 38:59cardiology patient could go about
• 39:00their everyday life when they
• 39:02experience what they feel like
• 39:03in a regular heart activity,
• 39:05push the button on the
• 39:06ZeoPac
• 39:07and report in the synced
• 39:08phone app, what they are
• 39:09experiencing.
• 39:11And this device is then
• 39:12removed and mailed at the
• 39:14end of the seven or
• 39:15fourteen days, after which the
• 39:17clinician receives the Zeo Patch
• 39:18report and guides clinical decision
• 39:21making when identifying,
• 39:22types of arrhythmia.
• 39:24So this is just kind
• 39:25of it struck me as
• 39:26a an example of how
• 39:28this is not what we're
• 39:29talking about and what we're
• 39:31referring to,
• 39:32isn't
• 39:33hypothetical.
• 39:34And this, idea of,
• 39:37creating an EMA report, which
• 39:39is something that, clinics have
• 39:40started to do,
• 39:41is a way of, leveraging
• 39:43some of the data that
• 39:44we're already collecting through our
• 39:46research studies,
• 39:47and then partnering hopefully with
• 39:49clinicians to, figure out what
• 39:51would be the most
• 39:52clinically meaningful and helpful things,
• 39:55for providers to know, let's
• 39:56say, before a session begins.
• 40:00Finally,
• 40:02even after identifying who is
• 40:03at risk and why, there
• 40:05remains a question of what
• 40:06exactly to do, if someone
• 40:08does appear to be at
• 40:09risk.
• 40:10My third newest line of
• 40:11research seeks to mitigate suicide
• 40:13risk through key intervention targets.
• 40:16And the one I'll speak
• 40:18most about is pertaining to
• 40:20this construct of future thinking.
• 40:22And it takes on more
• 40:23of a resilience kind of
• 40:24framework trying to help those
• 40:26at risk, trying to connect
• 40:27with the alternative path of
• 40:29continuing to live.
• 40:31And we've started to explore
• 40:33future thinking as an intervention
• 40:34target in two ways. So
• 40:36the first has been through
• 40:37testing a ten minute cognitive
• 40:39exercise
• 40:40in which we coach youth
• 40:42on ways to generate more
• 40:43detailed mental image
• 40:45of their life events. And
• 40:46what we found is that
• 40:48this ten minute exercise improves
• 40:49the quality of future thoughts,
• 40:52and the number of internal
• 40:54details that they generate.
• 40:56We also,
• 40:57administer to control narrative
• 40:59style task and observed no
• 41:01change in general narrative style
• 41:03before and after this induction.
• 41:04It really seemed to be
• 41:05specific to the quality of
• 41:07future thoughts that they were
• 41:08demonstrating.
• 41:10A separate approach,
• 41:11for the lack of a
• 41:12better term,
• 41:13is, through brain exercises through
• 41:16a ninety minute interactive fMRI
• 41:18scan session
• 41:19that focuses on the ventromedial
• 41:20prefrontal cortex,
• 41:22a part of the brain
• 41:23I I referenced earlier, which
• 41:25we know demonstrates this blunted
• 41:27activity among depressed suicidal patients
• 41:29while they're imagining their future.
• 41:32And during the scan session,
• 41:34we show suicidal patients the
• 41:36live,
• 41:37degree of hemodynamic activity,
• 41:39in their own VMPFC while
• 41:40they're imagining their future shown
• 41:42in the red bar here,
• 41:43while providing them with a
• 41:44target level activity, blue bar,
• 41:46to reach.
• 41:48And this is a noninvasive
• 41:49and nonpharmacologic
• 41:50procedure,
• 41:51avoiding the typical side effects
• 41:53when prescribing medication,
• 41:55and so far has been
• 41:56tested among a handful, I
• 41:58believe, six, depressed suicidal patients
• 42:01who reported this to be
• 42:02a feasible and acceptable intervention
• 42:04approach.
• 42:08And then I referenced safety
• 42:09planning earlier as
• 42:12kind of intertwined with this
• 42:13idea of future thinking.
• 42:15But we haven't actually tested
• 42:16this yet. And so, one
• 42:17thing that we're hoping to
• 42:18launch, also this summer,
• 42:21is looking at the quality
• 42:22of safety plans in reference
• 42:24to,
• 42:25first, the quality of future
• 42:27thinking, baseline quality of future
• 42:28thinking that suicidal adolescents display.
• 42:30Can they anticipate
• 42:32a greater number or a
• 42:34more realistic set of coping
• 42:35strategies that they might enact
• 42:36in an anticipated future crisis,
• 42:39and then combining that with
• 42:40the idea of a specificity
• 42:42induction. So if we do
• 42:44implement something like a ten
• 42:45minute cognitive exercise,
• 42:47I make no claims about
• 42:48this type of ten minute
• 42:49exercise actually
• 42:50curing suicidality
• 42:52or helping someone be hopeful
• 42:53forever.
• 42:54But if there might be
• 42:55some key moments in the
• 42:57delivery of,
• 42:58known existing intervention strategies that
• 43:00may boost the effectiveness of
• 43:02those intervention strategies, such as
• 43:04safety planning, Might that be
• 43:06a way in which we
• 43:07can pair
• 43:09that ten minute exercise in
• 43:11a meaningful
• 43:12and beneficial way?
• 43:15In terms of next steps,
• 43:17we aim to go beyond
• 43:18internal experiences
• 43:20and focus on also the
• 43:22social context in which suicidal
• 43:23youth exist.
• 43:25So starting with the home
• 43:27and the relationship with their
• 43:28parents.
• 43:29So I think I mentioned
• 43:30this during the associates meeting
• 43:32in the fall,
• 43:33which is an observation that
• 43:35we've made time and time
• 43:37again across our studies and
• 43:38that I've seen clinically is
• 43:40that suicidal youth and their
• 43:42parents are not necessarily on
• 43:43the same page.
• 43:44And what I mean by
• 43:45this is that there's often
• 43:47fair to poor levels of
• 43:49parent child agreement when it
• 43:50comes to,
• 43:51the,
• 43:52degree of suicidal thoughts and
• 43:54behaviors that the youth is
• 43:55experiencing.
• 43:56And we've also found adolescents
• 43:58being concerned about fear of
• 44:00negative reaction in their parents
• 44:02or guardians or their sense
• 44:03of self reliance, as reasons
• 44:05to not disclose.
• 44:07We've also observed alarmingly,
• 44:09greater,
• 44:11degree of discrepancy
• 44:12between parent and child report
• 44:14about youth suicide risk,
• 44:17when it comes to racial
• 44:18and ethnic,
• 44:19groups.
• 44:20And so this,
• 44:22is in part informed by
• 44:23prior work in my lab
• 44:25led by my mentees, Carrie
• 44:26Ann Bell and Ilana Gratch,
• 44:28showing that when we examined
• 44:29a demographically diverse,
• 44:31set of parent youth dyads,
• 44:33a hundred percent of Asian
• 44:34American parents shown in red
• 44:36here were unaware or did
• 44:38not report suicidal thoughts and
• 44:39behaviors that were endorsed by
• 44:41their child.
• 44:43And so starting with,
• 44:46kind of focusing on, the
• 44:48home and really the Asian
• 44:49American immigrant community,
• 44:52in collaboration with, counseling psychologist
• 44:54Cindy Huang at University of
• 44:56Oregon,
• 44:57we are, I believe, this
• 44:58week, launching, the family checkup
• 45:01adapted for, Asian American immigrant
• 45:05populations.
• 45:06And so the family checkup,
• 45:07some of you might be
• 45:08familiar with this, is really
• 45:09taking parent report and child
• 45:11report about family functioning as
• 45:13well as about,
• 45:15both the strengths as well
• 45:16as areas of improvement in
• 45:17each of their views,
• 45:19collecting those pieces of information
• 45:21separately from those informants,
• 45:24as well as their views
• 45:25on how the child is
• 45:26doing. And then bringing together
• 45:28in session two, both parent
• 45:30and child and really navigating
• 45:31kind of where the discrepancies
• 45:33lie,
• 45:34in how each view family
• 45:35functioning as well as the
• 45:37youth functioning.
• 45:39And so,
• 45:40Cindy is,
• 45:41leading the charge in,
• 45:43and starting in Chinatown with,
• 45:46piloting this family checkup,
• 45:47specifically among those who experience
• 45:50among youth who are self
• 45:51reporting suicidal thoughts and behaviors.
• 45:54And tied to this study,
• 45:56we're also I I'm glad
• 45:58to have convinced Cindy. It
• 46:00didn't take much convincing, but
• 46:02to also look at parental
• 46:03attitudes toward mental illness, especially
• 46:05in this community.
• 46:07So, actually referring back to
• 46:09some of the implicit bias
• 46:10work that,
• 46:11I had done earlier on,
• 46:14we're actually approaching,
• 46:15this question of implicit bias
• 46:17in a different way rather
• 46:18than looking at implicit bias
• 46:19toward death or life. Instead,
• 46:21in this case, looking at
• 46:22implicit bias toward mental illness
• 46:24relative to physical illness. And
• 46:25so there are these mental
• 46:26illness
• 46:27IATs,
• 46:28that have been,
• 46:30developed,
• 46:31and using these a mix
• 46:32of implicit and explicit measures,
• 46:34delivering that to the first
• 46:36time to parents of youth
• 46:38to observe correspondence with help
• 46:40seeking behaviors as well as
• 46:42youth outcomes.
• 46:45We also know that apart
• 46:47from physical surroundings, digital and
• 46:49social media has a dominating
• 46:50presence in the lives of
• 46:52youth today. And so some
• 46:54of our initial work shows
• 46:55us that nearly fifty percent
• 46:57of all suicide related disclosures
• 46:59now occur through digital and
• 47:00social media.
• 47:02Meaning wherever we fall in
• 47:03terms of the pluses and
• 47:04minuses of digital and social
• 47:06media use,
• 47:08youth are turning to digital
• 47:09interactions regardless
• 47:11and view it as a
• 47:12viable source of support.
• 47:14And so in future work,
• 47:15we hope to evaluate and
• 47:16improve evidence based and ethical
• 47:19engagement,
• 47:19of support,
• 47:21and support around suicide related
• 47:22disclosures
• 47:24online, whether that's through anonymous
• 47:26forums, peer to peer engagement,
• 47:27or how youth are turning
• 47:28to Gen AI even for
• 47:30support.
• 47:33So as a final step,
• 47:34I wanna touch upon,
• 47:36is it's honestly a question
• 47:38I I'd like to say
• 47:39we ask ourselves
• 47:40often,
• 47:41but there's always room for
• 47:42growth and learning,
• 47:43from others' experience and wisdom.
• 47:46And it's exploring the question
• 47:47of what my team and
• 47:49I as researchers are missing.
• 47:52There's much, I gained from
• 47:53my interactions with youth and
• 47:55families,
• 47:57and and other clinicians,
• 47:59in both research and clinical
• 48:00context.
• 48:02But in terms of the
• 48:03actual perspective
• 48:04of being a teenager, it's
• 48:06been a little while since
• 48:07I was fifteen, sixteen years
• 48:09old.
• 48:10And fortunately,
• 48:11that's not the case for
• 48:13our high school intern, Ria
• 48:14Ahn,
• 48:16who, joined us here at
• 48:17the Child Study Center, who's
• 48:18helping us build, a research
• 48:20community partnership starting with a
• 48:22partnership directly with youth.
• 48:24So we're in the process
• 48:25of building a youth advisory
• 48:26board,
• 48:27where we expect to advertise
• 48:28in the summer for members,
• 48:31likely individuals,
• 48:32youth, who have a personal
• 48:34connection to suicide, whether that's
• 48:36their own lived experience,
• 48:37but or knowing,
• 48:39a loved one or friend
• 48:40who has been affected directly.
• 48:44And so that's hoping we're
• 48:45hoping to launch that in
• 48:46the fall as well as
• 48:48youth navigate,
• 48:49an initiative led also by
• 48:51Ria to make mental health
• 48:52research more accessible to young
• 48:54peers.
• 48:55When Ria was doing a
• 48:57a lit search on youth's,
• 48:59advisory boards, one thing that
• 49:01she observed in terms of
• 49:02youth feedback is
• 49:04teens don't feel like they
• 49:05really yes. They can comment
• 49:07on the research that's brought
• 49:08to them in a youth
• 49:09advisory board meeting, but they
• 49:11don't they're not familiar and
• 49:12actively consuming
• 49:13the peer reviewed research,
• 49:15that we many of us
• 49:16researchers take for granted.
• 49:18And so,
• 49:19Ria had this thought of,
• 49:21developing youth navigate. What navigate
• 49:23stands for is escaping me
• 49:25right now, but Ria could
• 49:26tell you.
• 49:28And,
• 49:29but the idea of it
• 49:30is really to make mental
• 49:31health research more accessible,
• 49:34to teens.
• 49:35So by teens and for
• 49:36teens and communicating the science
• 49:38that we and other labs
• 49:39do so that when our
• 49:41youth advisory board members are
• 49:42consulting, they're not only,
• 49:44drawing from their own lived
• 49:45experience,
• 49:47and the experience of their
• 49:48peers, but also their understanding,
• 49:50of the research.
• 49:53Finally,
• 49:54this talk really wouldn't be
• 49:56complete without pointing to really
• 49:58my excitement and our lab's
• 49:59excitement about growing research practice
• 50:01partnerships,
• 50:02both within the Yale Child
• 50:04Study Center, Yale School of
• 50:05Medicine through the Center for
• 50:06Brain Mind Health, as well
• 50:08as Yale New Haven Health
• 50:09broadly.
• 50:11And so forgive me. I
• 50:13was telling my team I
• 50:14feel like a little bit
• 50:14of a car salesman today,
• 50:16so excuse the but it
• 50:18it really I think I'm
• 50:19I'm so honored to have
• 50:20been given this time to
• 50:22share some of the work
• 50:23that we've been,
• 50:25trying to launch as, as
• 50:26quickly as we can here
• 50:28at Child Study Center. But
• 50:29in addition to the momentum
• 50:31that we've been building,
• 50:33I really would like to,
• 50:34invite you all to to
• 50:36consider approaching us,
• 50:38because we do have a
• 50:39lot to learn.
• 50:40So whether you have new
• 50:42ideas about risk and protective
• 50:43factors for suicidal youth based
• 50:45on clinical observations or lab
• 50:47findings,
• 50:47we couldn't possibly have all
• 50:49the answers.
• 50:50And there's such a wealth
• 50:51of information,
• 50:52and wisdom and experience,
• 50:54in this room and and
• 50:55virtually.
• 50:57Whether or not you are
• 50:58looking for patient resources, we're
• 51:00also, open and, available to,
• 51:03first of all, kind of,
• 51:04have an exchange around what
• 51:06are the existing resources from,
• 51:08the standpoint of providers at
• 51:09different levels of care,
• 51:11and then, having an exchange
• 51:13about what whether or or
• 51:15ways in which we could
• 51:16work together to come up
• 51:17with additional resources to,
• 51:20to support both families, but
• 51:22also the providers that support
• 51:23those families.
• 51:25And then whether you're interested
• 51:26in delivering new interventions for
• 51:28suicidal youth.
• 51:29Again, as I referenced earlier,
• 51:31this is a very new
• 51:32area for me and my
• 51:33work. I think historically, I
• 51:34didn't identify as an interventionist
• 51:36and still consider myself as
• 51:37having a lot to learn
• 51:39and very much, invite,
• 51:41the expertise again in this
• 51:42room to,
• 51:44to approach and have a
• 51:45conversation.
• 51:48And we're really kind of
• 51:49eager to for help also
• 51:50in collecting,
• 51:52any data driven insights on
• 51:53suicidal youth and their families,
• 51:54just referencing some of the
• 51:56time series tracking work that
• 51:57we're really eager to get
• 51:59off the ground.
• 52:00So this is my last
• 52:01car salesman,
• 52:03slide, but just the point
• 52:05being,
• 52:06let's talk our doors open,
• 52:07and we are at three
• 52:08fifty, George Street.
• 52:10So oh,
• 52:13promise two, three more slides.
• 52:15So in in conclusion,
• 52:18you know, closing on much
• 52:19of what motivates me surrounding
• 52:21this work,
• 52:22as intractable,
• 52:24as an outcome as suicide
• 52:25may seem at times, and
• 52:26this is the constructive optimist
• 52:28in me coming out again,
• 52:30is that suicide is preventable.
• 52:32And that this is a
• 52:33vision shared by those with
• 52:34lived experience,
• 52:36where the same teenage boy
• 52:38whose drawing I showed earlier
• 52:40created for us I was
• 52:41really honored and grateful that
• 52:43he created for us a
• 52:44contrasting vision of hope
• 52:46as well. He found the
• 52:47weather to be a very
• 52:48powerful metaphor for him, in
• 52:50which he described as reminding
• 52:52him that no storm can
• 52:53last forever and that the
• 52:54sun always has to come
• 52:55out. And it reminds him
• 52:56of the inevitable change that
• 52:58the future can hold.
• 53:00And even if it's raining
• 53:01now, I have hope that
• 53:02my future will be beautiful
• 53:03rather than scary. So it's
• 53:05that lived experience and perspective,
• 53:07that serves as the foundation
• 53:09of our lab's work now
• 53:10and moving forward.
• 53:21Fantastic questions for doctor Shah.
• 53:28Christine, that was impressive.
• 53:31I'm curious. I was struck
• 53:31by one of the things
• 53:32you mentioned really early in
• 53:33your talk that that little
• 53:35has been learned about predicting.
• 53:37And I was curious why
• 53:38you think that is. Like,
• 53:40are
• 53:41is it that just the
• 53:42complexity of the problem?
• 53:43Is it that it's not
• 53:44the same causes
• 53:46over time?
• 53:48Why I mean, like, there's
• 53:49so many, like, so many
• 53:51tools to apply now in
• 53:52this genetic understanding that I
• 53:53understand. Just curious about why
• 53:55you think that's the situation.
• 53:57Yeah. Good question.
• 53:58I'm gonna give a crude
• 54:00answer and say I think
• 54:01we've been underestimating
• 54:02how complex and multi determined
• 54:04suicide is. And I think
• 54:05it's it's crude because,
• 54:08I also
• 54:09we have so many more,
• 54:11even computational advances,
• 54:13at our disposal now that
• 54:14we didn't have fifty years
• 54:15ago. So I'm certainly,
• 54:17not suggesting that it was
• 54:18just poor selection of,
• 54:20predictors or I I think
• 54:22that there's been science evolves,
• 54:23and I think, with that
• 54:25comes new tools that we
• 54:26can use,
• 54:27now.
• 54:28And then kind of the
• 54:29other example really being we,
• 54:31for a long time, made
• 54:32that assumption that,
• 54:34there might be certain circumstances
• 54:35in which asking for subjective
• 54:37impression and recall of an
• 54:38extended period of time is
• 54:39appropriate.
• 54:41But for a a transient
• 54:42outcome such as suicidal thoughts,
• 54:44that does have some short
• 54:45term predictor predictors as well,
• 54:48we may have to actually
• 54:49increase the temporal resolution with
• 54:51which we're observing
• 54:52this outcome.
• 54:55Hi. I'm Laurie Cardone. I'm
• 54:57psychologist
• 54:58on our inpatient psychiatric unit
• 55:00for really little kids and
• 55:01also on pediatric consultation liaison.
• 55:04We see really young children
• 55:06have,
• 55:08an immediate,
• 55:09precipitant be a shaming
• 55:12experience in school.
• 55:14So I'm wondering what thoughts
• 55:15you have about extending
• 55:16your wonderful projects
• 55:18and partnering with local school
• 55:20districts. What what your thoughts
• 55:22are
• 55:22about the applicability
• 55:24of any of your projects
• 55:26to,
• 55:27public schools?
• 55:29I would absolutely
• 55:30love,
• 55:31that opportunity. In fact, when
• 55:33I first joined,
• 55:34on faculty at Columbia ten
• 55:36years ago, that was one
• 55:37of the first IRB protocols
• 55:39that I wrote, which was
• 55:40to the Department of Ed,
• 55:43IRB,
• 55:44to propose, you know, a
• 55:45suicide screening study. And,
• 55:48I understand they have their
• 55:49reasons, but we basically, after
• 55:51putting in a a forty
• 55:52page IRB proposal, got a
• 55:54one liner suicide is not
• 55:55an appropriate topic of study.
• 55:57So and there's there's history
• 55:59around that depending on school
• 56:01districts. And,
• 56:02and so, you know, I
• 56:03I think it was just
• 56:05not the time, at that
• 56:06point.
• 56:07And it was that that
• 56:08was a hard thing to
• 56:09accept, especially having been at
• 56:11the School of Education at
• 56:12Columbia, which does have a
• 56:13lot of ties to the
• 56:15school system. So I am
• 56:17very much eager to,
• 56:19to to try again,
• 56:20I think here in Connecticut.
• 56:24We have a question on
• 56:25Zoom. Chin, I'm not sure
• 56:26if you're able to unmute
• 56:28to ask your own question.
• 56:31Sure.
• 56:32So
• 56:33great talk. Happy to collaborate.
• 56:36I'm curious to hear about
• 56:37the study in facial microexpressions.
• 56:40Like, were you referring to
• 56:42the Duchenne smile? Were there
• 56:44others? So I'm just curious
• 56:45to hear more about that
• 56:46study. Thank you.
• 56:48Yeah. So that study is,
• 56:51still the the data itself,
• 56:53because we're looking at facial
• 56:55actions frame by frame,
• 56:57is has been a bit
• 56:58of a grueling process in,
• 57:00the preprocessing
• 57:01of the data. But we're,
• 57:03we're rushing to do that,
• 57:04unfortunately,
• 57:05again, through Ellen's help,
• 57:07expediting that through leveraging AI
• 57:09tools to automate that process.
• 57:11But going to,
• 57:14I appreciate you just giving
• 57:15the opportunity to elaborate more
• 57:17on that because there are
• 57:18also some key questions that
• 57:19are on our minds as
• 57:20we
• 57:21approach this type of work.
• 57:23So facial action and the
• 57:24idea of a Duchenne smile.
• 57:26Even within affective science, there
• 57:28are debates as to what
• 57:29exactly a Duchenne smile even
• 57:30means within the same cultural
• 57:32context.
• 57:34Even then if you look
• 57:35at cross culturally and, as
• 57:37you as you change different,
• 57:39cultural contexts and situations,
• 57:42a smile can mean lots
• 57:43of different things. And that
• 57:44is something that we're keeping
• 57:45in mind.
• 57:47Right now, I think a
• 57:48lot of it is,
• 57:50exploring
• 57:51even the feasibility.
• 57:53But,
• 57:54I I I don't. I
• 57:55was just telling,
• 57:57our our lab that,
• 57:58I think there's
• 58:00caution to put out there
• 58:01as well. We don't want
• 58:02this to just be the
• 58:03next shiny object and get
• 58:04excited about it and then
• 58:06realize later on, oh, wait
• 58:07a second. We should have
• 58:08probably trained this on a
• 58:09more diverse set of
• 58:11stimuli, or we should have
• 58:13checked the biases of expert,
• 58:15reviewers who are providing the
• 58:16ground truth,
• 58:18against which we're we're we're
• 58:19training the algorithms.
• 58:21And,
• 58:22and so that's that's something
• 58:24that we're keeping in mind,
• 58:25as well as we approach
• 58:29this. Thank you very much
• 58:30for your talk. My question
• 58:31is about your project that
• 58:34looked at facial expressions of
• 58:36providers who were assessing Yeah.
• 58:37I'm sure you say. Did
• 58:39you which had remarkable AUC
• 58:40scores. Did you compare those
• 58:42expressions
• 58:43against,
• 58:45provider assessment of suicide, or
• 58:47is that something you're considering
• 58:48doing? That's a good question.
• 58:50Thanks for asking that, Uche.
• 58:51I don't think we have
• 58:53compared it with clinician report.
• 58:55And I well and I
• 58:56should say these weren't clinicians.
• 58:57These were masters level and
• 58:59doctoral level clinical psychology trainees.
• 59:02And
• 59:04I don't think we had
• 59:05them actually provide some sort
• 59:06of subjective impression.
• 59:08In other studies where we
• 59:09have collected clinician,
• 59:11report,
• 59:14we've seen that when we're
• 59:16asking clinicians the likelihood of
• 59:18attempt of their,
• 59:19their suicidal patient,
• 59:21it's it's a coin toss,
• 59:23the the the accuracy,
• 59:24of those ratings, which is,
• 59:26I wanna be clear, not
• 59:27a a story, I think,
• 59:29about
• 59:31the the failure of clinicians
• 59:33or health care professionals. I
• 59:34think it speaks more to
• 59:35the complexity of suicide and
• 59:37the fact that clinicians are
• 59:38trying to make the best
• 59:39decisions as they can with
• 59:40the data that's available.
• 59:42Right.
• 59:44Yeah.
• 59:45It's remarkable that you can
• 59:46have that as something that
• 59:47actually also helps your own
• 59:49assessment as a clinician.
• 59:50If that's something that improves
• 59:52your objective, you know, the
• 59:53confidence in your assessment I
• 59:55think you're following objective.
• 59:56Exactly.
• 59:57You're following Ilana's train of
• 59:59thought with, I think, probably
• 01:00:00where she's going with her
• 01:00:01research tied to this. So
• 01:00:03just one last point to
• 01:00:04make. In keeping with the
• 01:00:06theme of showcasing fantastic,
• 01:00:08expertise and science here in
• 01:00:10the Charles Study Center, next
• 01:00:11week, we will have our
• 01:00:12t thirty two,
• 01:00:13trainees presenting, Elia, Ghar and
• 01:00:15Dan Doyle. So please do
• 01:00:16join us for that. And
• 01:00:17just thank you once again,
• 01:00:18Christine, for a fantastic presentation.