Podcasts for health care professionals

Introduction: Hi everyone, Thank you for joining another episode of Heart of the Matter, a podcast we created just for you to discuss important aspects of supporting cultural and mental well-being. I am your host Amy and I am a licensed clinical social worker, specializing in suicide prevention, intervention and postvention.

 

I have an extra special episode for you today, as we enter World Mental Health day and National Coming-out day.

 

In this episode you’ll hear from my friend and colleague, Carolyn Scully, as she gets host. She will be talking with Nova Bright, head of Internal Training at the Trevor Project .

 

The Trevor Project is a leading suicide prevention and crisis intervention organization for LGBTQ young people. In her role, Nova provides life-saving and life-affirming training for youths, serving professionals and adults.

 

In addition, Nova educates corporations, municipalities and organizations on LGBTQ competent suicide prevention, active allyship and creating inclusive intersectional environment, supportive of LGBTQ people.

 

Carolyn Scully: Nice to see you. I know this is not our first rodeo. This is our second.

 

Nova Bright: Hi, it's so good to see you again. No. Yeah, it is our second. I'm excited to get to talk again.

 

Carolyn Scully: You as well. So, before we dive into all the fun stuff we're going to talk about today, I would be more than happy to give the audience just a quick introduction of who I am and then I would love to hear about yourself and all the amazing work you do at Trevor. So, my name is Carolyn Scully. I go by she, her, hers pronouns. I'm currently a CVS health colleague in a corporate general management development program. So, I started my first rotation working in the mental health part of our business and I'm now in my second rotation focusing on our Minute Clinic mental health business where we have in-person and virtual therapy offerings all across the nation for Minute Clinic customers and patients. Personally, I live in Chicago, Illinois. I recently moved in with my girlfriend and our cat. I spend a lot of my free time running, listening to Taylor Swift, watching football, playing with my cat as a typical 24- or 25-year-old does in the city. And I've loved The Trevor Project. I've been familiar with their services for the past few years, and they are a strong partner of the company and the organization I'm involved in. I'd love to hear more about yourself, Nova.

 

Nova Bright: Yeah, so my name is Nova Bright Williams. My pronouns are she, her, and I am the head of internal training, learning and development for The Trevor Project. I've been with Trevor Project for almost a decade. It'll be 10 years in June. And let's see, I live in Burbank, California with my husband, an eight-month-old dog who is hopefully not gonna bark during our time together today, and our kiddo who is in high school. So that would be a little bit about me. In my free time, I like to build Lego sets and do outdoorsy stuff. California is real good for that. So, I live right at the foothills of the mountains and our dog is like a herding dog, so she needs so much outdoor time. So that's me. It's so good to be back with you though

 

Carolyn Scully: Yeah, you too. So, I know obviously we're here to talk about Trevor and the resources. So, I think it would be helpful for those who are not familiar with what it is. So, if you have a brief overview of kind of what Trevor is about.

 

Nova Bright: Yeah, that makes a lot of sense. So, The Trevor Project is the leading suicide prevention organization for LGBTQ young folks. We offer free, confidential 24-7 crisis services, and those can be accessed by calling, using a phone like the lifeline or texting, using a phone as well. And then we also have Trevor Chat, which folks can access our website, thetrevorproject.org. Get help is the button you would click. We also run Trevor Space, which is a safe space social network site for LGBTQ youth. And we have some amazing prevention programming as well. Our research team leads research on LGBTQ youth mental health and suicide prevention. Our advocacy team works to protect LGBTQ rights at the local, state and federal levels here in the US. And our education team works to educate and build allies for the LGBTQ community. We primarily educate adults who interact with LGBTQ youth. So that's a little bit of an overview about us.

 

Carolyn Scully: So about how long has Trevor been going on? And is there any potential anniversaries coming up that you think would be helpful to note?

 

Nova Bright: We just celebrated a really important anniversary, which is 25 years. The Lifeline launched back in 1998 when I was in elementary school.

 

Carolyn Scully: That's incredible. So, I came along right when Trevor came along in 1998.

 

Nova Bright: Okay, but that's also cool because you have lived in a world that always had the Trevor Project and so many LGBTQ adults say, you know, I wish I had this resource when I was younger. So that's pretty cool. Back in 1998, there was an Academy Award winning short film called Trevor and it was about a young gay teenager who was experiencing suicidal ideation and struggling. And that premiered on HBO and alongside it, premiering on HBO, we wanted to be able to offer a resource for folks to be able to reach out if, you know, watching the short film caused them to realize, hey, I would like support in this area. And thousands of people reached out and one thing led to another. And we realized, wow, this is a really necessary and needed resource. And all these years later, I think I was just reading this past year, we served over 144,000 contacts of people who reached out to one of our services, which is just a very difficult number, right? Because that means that there were 144,000 folks who needed support. But wow, are we grateful to be able to be there to offer that support.

 

Carolyn Scully: Right. Wow, that's incredible. I had no idea that it started from a short film. Do you know if that's something that is still on HBO? Like, could I go search and find it?

 

Nova Bright: I don't know, honestly.

 

Carolyn Scully: Oh, okay.

 

Nova Bright: I think, you know, it's available in certain places, maybe online. Yeah. Right, and Peggy Reiske, who's our founder and our interim CEO right now

 

Carolyn Scully: Okay, I was just curious.

 

Nova Bright: She was actually the director of that film. So, it's sort of special to have our roots here right now.

 

Carolyn Scully: Awesome. Thanks for sharing that. So going into the core of the services that Trevor has, I know you shared the number of folks who have called or texted in, which you're exactly right, I hear you. It's, well, that's amazing that it's a resource, but it's also incredibly heartbreaking to know that that's over however many youth, young adults, folks or anyone who has called into the service in need of it. So, it's a double-edged sword with that. So, what exactly happens if someone were to text or call into the line? Like Where are they directed to?

 

Nova Bright: Yeah, so I am the head of our internal training, learning and development team. And the reason why I'm answering your question with that is because my team is responsible for the development of our training and also the training of our crisis counselors. And when I tell you that we have some of the best, most amazing volunteers and staff who take calls, chats, and texts every single day for the Trevor Project, I mean, we have the most amazing people. If I had to think of a group of people that I would put my faith and trust in, it's these folks. And they go through extensive training to be available to folks who are in crisis. And if you were to reach out, you'll be connected one-on-one with a trained counselor who is there to listen, to offer support, to maybe help you plan and navigate through a particular crisis that you're going through. And that is really important for folks, especially the 24-hour piece, right? It's not always between nine and five that you have a crisis. It's hard to plan for them. So, you know, you might need a three in the morning friend and we can be that three in the morning friend.

 

Carolyn Scully: Right, and I think it's important too with youths who may, or young adults again, who may be struggling during this is that they are anonymous because for some folks, like this is the only place that they know or can turn to in a safe and secure way. And so can you talk a little bit about what happens if something needs to be escalated to either authorities, parents what is the process when something like that happens.

 

Nova Bright: Yeah, I think that makes a ton of sense that that's on folks' minds, right? A lot of times you're reaching out because you don't have a healthy or safe support system in your community or in your family. And so, you're looking for that safe support system that's anonymous. And that is, you know, there for you without necessarily you having to connect to people that you don't trust or you know, people in your community that aren't safe folks for you. Now, the reality is sometimes you do need in-person help or support when you're in the middle of a crisis. Ideally you would partner with one of our counselors to get you to the support that you needed. If you did need in-person support beyond just someone to listen and to talk through and to help plan, safety, maybe you do need to reach out to someone in person and we can help you in that way. We can help connect you to resources in person. But ideally this is a partnership, right? Where you are in control, where you understand sort of what your options are and what's best for you. And occasionally that does mean emergency services supporting you, right? The interesting thing about crisis is that when you're in it, it feels like it's forever. It feels like it's not going to stop, you know? And when you're outside of it and you have some perspective to look back on, you realize, oh, I wasn't necessarily thinking clearly in that moment because there was so much to navigate related to just the overwhelming feelings, right? And all the chemical reactions in our bodies and all of the various things that sort of happen. That's something that you need to sometimes partner with a real live person. That's the other point I wanted to make because every so often we hear rumors of people being like, oh, you know, it's just a bot or it's AI or there isn't a real person answering these calls or chats or texts. And that's not true. It's always a real person, right? When you first reach out, you might get some pre-questions, right? Just so that we can get to know you a little better while we wait to connect you to a real person. But you'll always be connected to a real person, right? Because that's the point. When you're in crisis and when you're feeling alone, you want to know that somewhere out there, a real person cares about you and is listening to what you're going through and supporting you through this moment. And so that's our goal, that supportive, affirming conversation with a real person who understands what you're going through and cares about you.

 

Carolyn Scully: Yeah, that's really important. And I think too, it just, I really like the emphasis that you had on that human connection. It's not something I thought about before with something like this. I really appreciate the narrative and making sure that human connection is there. I think that's really powerful and important to remind ourselves as either users of something like this or even not. I appreciate that. And the next thing I'm curious in hearing about, you spoke a little bit about this in your introduction. What is TrevorSpace? I know you said it, it sounds like MySpace, it sounds like Facebook. Like what exactly is it, who is it for, and how can users access something like that?

 

Nova Bright: Yeah, so the access part is easy, TrevorSpace.org. But the truth is TrevorSpace is a social media site that allows you to connect with other people who are around your age and who share similar identities to you. So, imagine being able to go to a site and connect to another trans person. Right? When I was younger, this is the part where I'm like, I'm a millennial, I'm cool, I'm hip, but, and now I'm gonna sound like I wasn't. But when I was younger, I literally didn't know there were other people like me. It didn't even cross my mind that I wasn't absolutely different from every single other person. It didn't even cross my mind that I wasn't the only person on planet earth going through what I was going through. And so when I think about what this means today, not only do we have LGBTQ stories being told, which come on, tell more, tell more. I love a good LGBTQ story. I cannot tell you how often I'm reading a book and when there's an LGBTQ character, I'm like, yes! I'm sold.

 

Carolyn Scully: I know. Sometimes it's so weird when you read something. I understand.

 

Nova Bright:But at the end of the day, when we are talking about the importance of being able to connect with others like you. That's where TrevorSpace is really a beautiful resource because not only can you connect to other people who are similar to you, but you can connect to them anywhere in the world. They could be, you know, a trans person who is living in India or, you know, a lesbian who loves anime and lives in London, right? Like there's so many different possibilities and it's not geographically tied, which is super important because some of us grew up in really small towns and, you know, it's difficult to find yourself in the community around you. So I love this as a resource and it is age-moderated, right? You would be connecting with other people under the age of 18, or if you're between the ages of 24 and 18, then you would be connecting again with other people in that age group as well. That's just to make sure that it's a safe space for you to connect to folks who not only are similarly identified but people who are, you know, around your same age.

 

Carolyn Scully: Right. And I think you bring up a good point and the ability for folks to connect with those who look, identify with them, all that fun stuff. But I think it brings up the important question. And you kind of touched on this and making sure this is a safe space. We live in an age now where technology is everywhere and that's both good and bad. And it brings us great things in the world, and it can be harmful in other ways. So can you talk to a little bit about how TrevorSpace is moderated? So, I know some websites have like quick escape or something like that. So, first part of my question, how do you ensure that your space is safe for the user? And then two, how do you ensure that it's kind of safe in private for whoever is on the site?

 

Nova Bright: Yeah, so that's a great question. I think there's a lot of different aspects here. Unfortunately, we live in a world where it's not always safe for LGBTQ youth. Sometimes their parents are not safe people. Unfortunately, if you look at pretty much every major city in the US, let's use our cities, for example, Carolyn, so Chicago and Los Angeles. Both of us have a really tragic statistic in common, which is that in our city, if you look at the portion of the population who are youth with unstable housing, so youth who don't have stable housing, 40% of those young folks identify as LGBTQ. And a big reason why that happens is because when they share with their family, hey, you know, I think I might be trans or I think I'm a lesbian or I think I'm bisexual or asexual. Their parents may say you don't have a place in our family anymore. You don't have a room here anymore. And so it's just not safe for everybody to be themselves. And so we do offer a pretty cool option if you do use our website. You can click escape three times and it will close the browser, like close the window and delete it from your history. So that way, if you are worried that somebody might realize that you are part of this community, but you don't feel safe to be outed in that way, you can have some anonymity there. Another really cool feature is the fact that TrevorSpace is moderated, right? So that means that there are folks who not only understand LGBTQ concerns but are there to ensure that conversations are appropriate and safe for folks. And that means if anything were to get flagged as inappropriate or concerning, a real person is checking that out and ensuring that it is, in fact, a safe space. And so, while the internet has made it nearly impossible to get it right 100% of the time, it is nice to know that there are folks who are working tirelessly to ensure your safety while using a service like this.

 

Carolyn Scully: And I hear you when you first were kind of mentioning TrevorSpace, you were just kind of talking about like, oh, like this kind of wasn't around when I was there. Things about for myself, I remember thinking, oh, the only other gay person I know is Ang Lee, so they're not real people. And the need for community is something that, again, I so would have needed. I'm glad it's there now for the folks who need it, and I'm glad it will be there for the future as it kind of expands in the next 25 years. So that's really cool to see.

 

Nova Bright: Yeah, it really is. It's one of the coolest things because it's not really dependent on a crisis, right? It's not like reach out if you're in crisis or if you need to speak to someone because things aren't going particularly well. It's sort of like you can go here and be like, I just bought my first dress or like I just finally figured out how to get my eyeliner correct or, you know.

 

Carolyn Scully: Thank you. Right. And getting that instant positive affirmation is something that's really powerful and we can all use more of. It's great to have support. I don't think anyone can deny that, so I think that's awesome.

 

Nova Bright: Absolutely.

 

Carolyn Scully: So for folks who are listening now who may or may not have used a service before, what kind of advice would you give to someone who is either struggling themselves or supporting somebody else who may be struggling?

 

Nova Bright: You know, I think there's this sort of like cliche where we say, you know, you're not alone, right? And I get that sometimes feels a little bit like, mm, no, but I feel alone. Like, okay, thanks for telling me I'm not alone, but I feel alone. And I think the truth is when we are feeling the most isolated, the most like we are different from everyone else and that there isn't safety for us and there isn't a space for us. The important aspect there is realizing, uh-uh, I'm not alone. There are other people. There are other people like me who care about me. There are people who are not like me in any way who care about me. The fact that at any hour of the day there is a real person somewhere in the world who is going to sit and listen to your story and connect with you. You know, one of the biggest protective factors for suicidal ideation is human connection. If you can connect to someone who meets you where you're at, who doesn't judge you, who cares about you, that is one of the biggest indicators of a reduction in suicidal ideation or a de-escalation from suicidal ideation. And that's what we're here to do. We're here to be that shoulder, virtually.

 

Carolyn Scully: That's awesome. And I think, thank you for sharing that and thanks for everything you shared today. It leaves me with just one feeling of wondering, I'm not currently involved in volunteering with the Trevor Project, but I would love to be. So, you can, you talk a little bit more about how folks like me or others who are interested can support the Trevor Project as a volunteer, activations, things like that.

 

Nova Bright: Absolutely. Our volunteers are the best. I am obsessed. And actually, I started as a volunteer almost 14 years ago. I started as a volunteer counselor on our lifeline before I came to Trevor and joined our staff. And the truth is you know, this community of folks who care, who are empathetic, who want to make a difference, there really is no volunteer opportunity quite like this. And it's what drew me here almost 15 years ago. It's what caused me to want to work on staff here. And I just want to say if it's something that you think that you have the capacity for, but you're like, oh, I don't really know how to do that. Don't worry, we have really good training. That's my team. And we're happy to train folks. It's not a volunteer opportunity for everyone, but if it is something that you are interested in, that's one way to get involved. Another way to get involved is to help support us financially. Of course, these services are very difficult to operate 24-7. And so having the financial resources to be able to do that is really important. And then of course we are in unprecedented political times. And so sometimes volunteering looks like supporting our work through activism, through advocacy. There are some places in the country right now where it is extremely unsafe for LGBTQ folks to just exist. And in those cases, having folks on the ground in those communities is really important. And so if you're like, hey, I'm in one of those states or one of those cities, we have some resources available for how to get involved and how to advocate in your community.

 

Carolyn Scully: Awesome. Well, I will be doing that. I'm sure folks listening to this will be more than excited to as well. I just wanted to thank you for your time, Nova. Thank you for your work at Trevor.

Thank you for helping Trevor keep existing 25 years ago up until today. It obviously continues to evolve with technology and things like that as we all grow and learn. And I appreciate you so much for being a sounding board for LGBTQ young folks all across the country. So thank you 100 times. I appreciate it. This is amazing work.

 

Nova Bright: Well, right back at you. I always enjoy these little conversations we have, and I so appreciate the opportunity to come here and share a little bit more about the work that we do in our mission.

 

Carolyn Scully: Thank you.

Dr. Schneider: Hi, I'm Dr. Alan Schneider. I'm originally a psychiatrist and a geriatric psychiatrist and then I became an addictionologist. And I have the pleasure today to be joined by Dr. Pamela Sheffield, and the two of us will be talking about dealing with issues of substance abuse and primary care. So let me turn it over to Dr. Sheffield for a moment so she can introduce herself.

 

Dr. Sheffield: Thanks. Hi, I'm Pam Sheffield. I'm a family doctor. I'm up in the Seattle area and was in practice for about 25 years up here. Thanks for having me.

 

Dr. Schneider: Thank you for letting me join you. So let me get started. Pam, I know that you practice primary care and that there's a lot of primary care physicians that we see, urgent care, OBGYNs, pediatricians. How do you think most primary care physicians now deal with the issue of substance abuse in the area of relatively short visits in their office? What do you think the problems they encounter?

 

Dr. Sheffield: I think that there's a lot of news and information about the urgency of the problem. Everybody is well informed that we're in a crisis in relation to substance use and I think that piece of it, the urgency is there. I think the thing that's challenging is the time, like you mentioned. There was just another article that showed that the average primary care provider, if they tried to do everything they're supposed to do in a visit their day would be 27 hours long. So we know that we're dealing with an incredible pressure for primary care to do all the things that they're supposed to do in a visit and we have a lot of very well meaning doctors trying to navigate that reality. And so it can be a challenge for any one issue to kind of rise to the top and to get the attention that it deserves in any given visit.

 

Dr. Schneider: Pam, it's interesting that you say that. It just got me thinking because I go to a colleague of mine who's a concierge internist, and he gives me excellent care, actually, I trained with him, and it occurred to me as you were talking that despite all of the things he goes into with me, he rarely asks about whether I drink. And I'm a very modest drinker, but it almost never comes up. So it really speaks to that issue about the intensity of the visit and the time of the visit and where issues of substance use comes in an average visit.

 

Dr. Sheffield: And it talks to the issue of bias too, right, because that's one of the things that comes up when looking at substance use issues is that if you're looking across the desk at someone who looks like you and acts like you and has your background, it's really easy to make assumptions about whether that person could have this type of problem or not. And so I think that in the era of health equity and wanting to be providing excellent care and consistent care to all of our patients, we need to think about how we integrate this into our practice universally and we don't make assumptions about who has a problem and who doesn't have a problem. And I think that's the challenge of screening and how do we work universal screening into, again, that really busy schedule.

 

Dr. Schneider: Pam, I think those are really excellent points, and I think we're going to get back to the issue of universal screening in a moment. But let me ask you something, do you think that the average primary care physician or even specialist has enough resources available to them to deal with such an immense problem that we have here?

 

Dr. Sheffield: Yeah, I think that's an area where there are some gaps. And I think that the issue of having the resources at hand and having simple resources that providers can become facile with that they feel confident that they have that in their toolkit to manage is a challenge and that was one of the things I was hoping we could talk about today is how do we introduce some reasonably quick but effective interventions and tools for the primary care providers to have on hand.

 

Dr. Schneider: Good. Well, let's delve right into that if we can. So primary provider gets a patient who comes in and they have a sense that maybe there's a substance issue here. What are some potential strategies that you see that they can employ? I'll talk a little bit about some of them too, but let's go first with you. What do you see as a strategy that can be employed?

 

Dr. Sheffield: Yeah, I think that there are a couple pitfalls that people get into, and one of them is trying to do everything all at once. And so I think that with all the pressure of there's a crisis, people are dying, the primary care providers can get overwhelmed and feel like they really have to address the issue in a comprehensive way in order to be effective and also to achieve abstinence. And so I think that that can end up overwhelming people and if they can find a way to break it down, break it down into reasonable pieces that you know can employ in your practice, it can be less overwhelming and use tools that primary care providers already have because we have tools for dealing with tobacco cessation, smoking cessation, and when we can use those simple tools like motivational interviewing for example, where is the patient in their journey so that you know what resources to connect them with.

 

Dr. Schneider: Yes, and I know you and I have spoken about this before, the value of a very brief motivational interviewing that even that, just one intervention, can make a great deal of difference in many people with mild use disorders. And as I was talking with you about the other day, even a patient of mine who was drinking a little bit more, just the idea of talking to her about how much she was consuming, two glasses of wine a night, was enough to get her to cut down and say, "I really have to reduce this down to one and just one maybe only a couple of times a week." And that was just a brief intervention and very easy to do. So not seeking to achieve complete abstinence, but maybe just one brief discussion at times would be enough.

 

Dr. Sheffield: Right. And I think that physicians, we're high achieving people, very well meaning and wanting to do the right thing and one thing I hear physicians time and time again is, "Well, I didn't do anything. We just talked." And I think that it's good to remind people that just having a brief conversation and repeating that over time can really impact outcomes for people in regards to their substance use. And I guess one of the things I want to do is just encourage people that you don't have to fix it in one visit, but saying something is better than ignoring and if you screen and you have the opportunity to have even a very brief conversation that's valuable. And over time that can lead to real change and impact.

 

Dr. Schneider: And the idea of multiple brief interactions so that if it doesn't get done the first time, you get a chance to revisit it with a patient at a later time and not to feel defeated because you didn't get an outcome on that first intervention.

 

Dr. Sheffield: Right. I think the more gentle providers can be with themselves and understanding the limitations of what the reality of the visit is and doing your best, but not expecting complete success at one visit.

 

Dr. Schneider: Exactly. I also wanted to take this opportunity, if it's okay with you, to talk about providers having an understanding of what's in their community in terms of resources, because there are various levels of care in the community and I think a provider needs to know that if it's a more severe condition, they can refer out to higher levels of care and higher levels of care start with intensive outpatient programs, for example, that meet three times a week to... or sometimes even five times a week, to partial programs that go longer during the day, five to six hours a day and those meet five times a week up to six times a week. And then there are residential programs where people go 24 hours a day all the way up to inpatient detox and that one doesn't feel like they have to do everything themselves, they can recognize a more severe problem and they can use a community resource to help them so that they don't have to feel saddled with the entire responsibility of treating a patient.

 

Dr. Sheffield: Right. And we know that if we're going to manage patients well given the time constraints, we need a team around the patient. The primary care provider can't carry that burden all themselves.

 

Dr. Schneider: Exactly. I know you were interested in screening tools, weren't you?

 

Dr. Sheffield: Yeah. So I think this goes back to it's difficult to keep track of all the things that you need to do and so if we can encourage people to use a simple screener and to get that conversation started, then when that question's asked, you tell people, I just ask everybody, and you can bypass the pitfall of picking and choosing who you screen, but it needs to be something quick and simple. So what do you recommend?

 

Dr. Schneider: I think that's really an excellent question. And I think that it depends on which tool you want to use, obviously and how long they are. But there are very simple tools like the SISQ, which is a single question screener that asks somebody if they've used drugs in an inappropriate manner, there's the audit or the audit C, which looks at alcohol, the audit is longer, the audit C is shorter. These are validated tools over time. There's the DAST 10, which looks at drugs of abuse. There's the Craft, which is for adolescence. And the idea behind all this is there's plenty of tools, there's no shortage of tools, screeners that you can use. The concept being that you choose one that you like, you become familiar with it, you adopt it for your office and you really give it to your population And it can be used in the waiting room where somebody fills it out on their own, these are very quick tools to fill out, and then it becomes a springboard for discussion after that. And I have routinely used these and people tend to fill them out fairly... with fair validity actually. And then if I pick up anything, I use it as a discussion point after that. And I think it's a very easy way to go about screening people and talking with people and really kind of interesting discussions emanate from that with people who otherwise would not necessarily offer up a history of alcohol or substance use.

 

Dr. Sheffield: Exactly. Yeah. And I mean, as a family doc, I like the idea of one question because with every visit, we're screening for multiple things and we need something that's simple, embedded in the EMR and just embedded in the rooming process so that we can pick up the people that aren't obviously having a problem related to substances.

 

Dr. Schneider: Right. And most of these tools are available in standard EMRs. They're out there, so it's not hard to incorporate them in. So let me ask you, should we be screening any particular groups when they come in? Should screening be universal? What do you think about that?

 

Dr. Sheffield: Honestly, I have strong feelings about that. And I know in my own practice, I have had the experience of managing a patient who was really giving me a lot of red flags. And this was a woman who looked like me and talked like me and had a similar background to me, and I just completely missed the fact that she was spiraling down in using her substances. And so I think we've all had those experiences on both sides of it where we were suspicious of someone based on how they looked or how they talked or what their background was and we were wrong about that. I think the thing that happens more frequently is we overlook certain populations because we have bias about what their risk is. And so I am a strong believer in universal screening, as I said before. I think that that makes sense from a health equity standpoint. And then when you do have people that come in and they're nervous about feeling like they're being profiled or accused of something, then you have the option to tell them, "I'm not singling you out. This is something we ask every single patient." And you just ask it along with what are their medications and do they drink alcohol? And it's just another question you ask. And so you can normalize it. And I think patients will often say, "You're accusing me of something." There's such a stigma associated with using substances that doesn't apply to a lot of other medical conditions. And you want to avoid making people defensive. You want it to be an open conversation where they can share with you.

 

Dr. Schneider: Yeah, I agree wholeheartedly, and I think this is a very strong take on point, that universal screening is really necessary, even though we know that there are higher risk groups, for example, people that are perhaps 18 to 24 or 24 to 30 with higher uses of cannabis, for example, in this country. Nonetheless, there are these groups, for example, the geriatric group, where you see someone come in who looks like your grandmother, and you say, "Well, this person can't possibly be using cannabis or an opiate." And you find out, in fact, they are. And there is this inherent bias in a lot of groups that they wouldn't be using substances, and you find out that they are. So that's really the purpose of universal screening and it's the recommendation that everyone be screened. And what you said is actually correct, that people tend to be put off by it, but it has to be normalized as this is just a standard part of what we do for everyone.

 

Dr. Sheffield: So here's a question for you from a family doctor perspective, what age do you start screening?

 

Dr. Schneider: You really start screening in the early preadolescent stage, believe it or not, because we have the monitoring the youth population studies that show that even back in eighth grade and even a little younger kids start using alcohol, they start using cannabis and they need to be screened too. So it goes from them all the way into the seventies and eighties where we know that people in that age group are using alcohol, they're using cannabis and believe me, they're still actually using opiates starting from an earlier age, or sometimes even from a later age when they've been treated with opiates for pain and then it gets out of hand. So there's no age not to screen, except perhaps in neonates, but it's really everyone.

 

Dr. Sheffield: Yeah. Yeah. I had a practice I covered for a while doing medication assisted therapy and listening to the stories of people, most of them started their opiate use in high school or younger, so it'd be good to catch those early.

 

Dr. Schneider: Early intervention is the thing.

 

Dr. Sheffield: And I think the next thing that primary care docs will say after we say you're going to screen and you've got these questions, I think the next pitfall that people run into is hopelessness, feeling like the problem is not easily treatable that people are doing this to themselves and so that's something I hope we can address is injecting some hope and helping people understand where these brief interventions can be helpful, what kinds of tools there are to really impact the toll, I guess, of substance abuse on the population.

 

Dr. Schneider: Well, we can jump right into that. I mean, there's no reason for therapeutic nihilism in any of these folks. Even if you're not doing the primary treatment yourself, there's the concept of harm reduction, which has been accepted for many years now that I think even primary care physicians can jump right into, which is if the person's not going to stop completely, what can I do to minimize their risk? And this can be a whole host of things. For example, starting with even offering someone who's using opiates naloxone, which is considered just standard now for people to do. And that's a lifesaving maneuver prep, for example, for people who are injecting drugs. Giving options for safe sex, condoms, is very important, or birth control. Needle exchanges, not everybody does that, of course, but it's out there. People do that. Fentanyl test kits, again, a lot of physicians don't necessarily offer that, but you can direct people to that. And these are lifesaving maneuvers and people don't necessarily think about that. But given that fentanyl is incorporated into just about everything these days and people don't know they take it, they have sudden overdoses. So when you take a step back and you think about, "I could do this and I could save lives," and the number needed to treat is remarkably so low for some of these procedures and the effect size is so great that it is such an important thing to consider to do some of these things office based, or at least refer them to people who can do it, that in some ways it outstrips the idea of let's go for total abstinence and refer them to a facility right away.

 

Dr. Sheffield: So what you're saying is a provider in primary care prescribing naloxone could save more lives more quickly than prescribing diabetes medications or high blood pressure medications.

 

Dr. Schneider: That's actually true and the ratios are really astounding when you look at that. The number needed to treat to save one life when it comes to a hypertensive medication versus naloxone is very different. Naloxone comes out much higher. So, something to consider.

 

Dr. Sheffield: Yeah. And I think that's the hopeful message. The hopeful message is if you screen for this and you find it, you have an intervention, you have multiple interventions and tools that really can make an impact. And I think sometimes the sensationalism of the media about the death, it can overwhelm people and make them feel hopeless. And one thing I'm hoping that we can achieve is to give people hope, to give providers hope that this is something that if you find it, you can make a real positive influence. And that's what providers and practice want. They want to help people.

 

Dr. Schneider: Absolutely. And I think people really minimize the idea that a small intervention, we've been talking about this back and forth, can have a large effect size. So even someone who drinks and says, 'Doc, I'm not really ready to stop all my drinking right now," to say, "Who drives you home?" "Well, I drive myself home." "Well, have you ever thought about getting somebody to drive you home or Uber?" There's a large effect size right there in terms of deaths from motor vehicle accidents and those kind of small interventions are very important and something that can be done in the office very easily.

 

Dr. Sheffield: Oh, I was going to ask about, can we touch on some of the other forms of therapy for substance use?

 

Dr. Schneider: Sure. So we can move on to medication assisted therapy. So there's several major forms of medication assisted therapy for alcohol and opiates at this time. So for alcohol, we have naltrexone and naltrexone injectable, there's the oral and the injectable, acamprosate. Disulfiram has really fallen out of favor for many years because of the metabolic disturbances of the drug can cause when people get sick. And interestingly enough, if you go back into the literature, disulfiram really did not show a positive effect when it was first studied in the 1950s and forward. So there's a small group of people who are disulfiram advocates, and I mean patients, not physicians as it turns out, who still believe the drug works and for those people, that's great. And I've had people like that and they preferentially want to take it and that's fine, but they're really a minority these days.

 

Dr. Schneider: So naltrexone really is an outpatient medication. You do not need to go into a facility to get it. You can give it in the office. It's easily administered, including the injectable form. It works very well as long as people remain adherent to it. And it's not hard to set up a schedule to get somebody to come back and take the injectable form. Acamprosate, a little more difficult to give to people, tends not to be as easy to take, so it hasn't been a number one drug for alcohol use disorders, but still there. And then when we move into opiate use disorders, a lot of people don't recognize that buprenorphine is something that's really office based. Talking about buprenorphine and methadone, these are the two most effective drugs we have in our armamentarium really appropriate use disorder. The drawback of methadone and excellent drug is that you have to be associated with the methadone clinic, of which there are limited numbers in the community. When I was at the VA, it was easy to have access to a methadone clinic. We had one right there. Major VAs have them.

 

Dr. Schneider: But then there's a sparsity of them in the community often where they're privately run and they don't always have treatment programs associated with them, which is very important. You have to have a treatment program associated with the dispensation of either of these drugs. Buprenorphine, it can be done out of the office, it can be done in an outpatient treatment program, what's called an OBOT, you can do induction, as I mentioned, in the office. Very effective medication like methadone. Both have an extended half-life, and both can be used for pain management, which is a great concept there. Where you have drugs that are long lasting, 30 hours, can be split up into BID or TID dosing so that you have the issue of the hyperalgesia, which is kind of covered when people are coming out shorter acting opiates. And that's a real strength. And plus their ability to reduce recidivism for people who've been in and out of the hospital a lot with opiate detoxes, these are wonderful agents to use. Buprenorphine either in oral or injectable forms or long-acting injectable forms. So a lot in our armamentarium to treat these patients.

 

Dr. Sheffield: So we have great tools to use to help people decrease or stop their use of opiates, harm reduction techniques. One of the barriers I see to more primary care providers incorporating this into their practice is some of the bias they have about people that use substances. And you'll hear providers say that they don't want to bring more people who use substances into their practice because people are going to behave badly and they're going to lie. And so how do we address that bias and help people understand and think more gently about people who use substances?

 

Dr. Schneider: Well, Pam, this is a really common misconception, that these patients look different than you and I. And it's really not accurate, that the vast majority of these patients come from the ranks of people we know. And many of them are working, many of them have families, and they're struggling. And in terms of treating them, they can be treated in the office setting many times they need a different structure of treatment in the sense that they don't look different, they're not going to disturb the rest of the population, they have a higher incidence of coexisting mental health disorders that need to be treated separately. But we have things that can help with their treatment. We can have, as I said, cures reports, PDMP to use in treatment to make sure they're not getting substance... treatment rather from other physicians. And we have urine testing in hand when we need it. And we have compacts that we enter in with the patients so that they know right up front what we're going to be doing, how we're going to be doing it, what they need to engage with. And when that's all set up properly with the patients, there's no reason why treatment can't go properly forward with most people. If it doesn't go well at that level, then we have this idea of what higher level of care do they need to be in for treatment to go properly? So that being said, there's no reason to not give it an attempt at a lower level of care first. I had a patient, as I was telling you privately, that was working in a medical office, this was a large worker's comp office, and he had free access to opiates and he became dependent on opiates. And he entered into our outpatient opioid clinic and was subsequently put on suboxone.

 

Dr. Sheffield: And through treating him, his employer was very generous with him and allowed him to keep his job, he was the manager of the clinic, and into his suboxone treatment, he lost all cravings for opiates. And he had the keys to the opiate cabinet, which was very interesting. He managed to go forward in full employment in that clinic. He was employed there. He had a family. He was one of many people that we treated that did beautifully and never had to rise to a higher level of care because he had this incentive to keep everything he had. And this just shows you that people can do very well if they're incentivized, if they had things that are important to them. These are not isolated cases. These were very common cases for us.

 

Dr. Sheffield: That's great. So we have simple screening, we have brief interventions that don't have to solve the problem and then we have options for primary care providers who want to do more for their patients with the option of prescribing medication assisted therapy.

 

Dr. Schneider: Absolutely. Any wrap up comments that you have? Any thoughts?

 

Dr. Sheffield: I want to make sure we're giving a hopeful message. We know we have a big problem on our hands, we know as physicians we contributed to the problem with prescribing behaviors in the past. It's not a problem that we're going to fix overnight, but with steady progress, with screening, with brief interventions, with therapy options, that we really can make an impact and some of the interventions we have might be some of the most impactful tools we have in our practice.

 

Dr. Schneider: I think you're absolutely right. And I want to put one feature in, which is that we've gone completely in the other direction and where for procedures, people will not even give two or three opiates to somebody after they've had an invasive procedure. And I won't say who this is, it's related to me, but they had an intervention on their shoulder, and this is an orthopedic group, and they said, "We don't give Vicodin anymore." And this was a fairly painful procedure. And that's not the take home message here, the take home message, we should still be giving pain management, we should still be trusting people. The idea here is not to eliminate all opiates and not to eliminate pain management, but to take the people who are really in need and treat them. And I think there's been so much press about "be careful who you prescribe for, don't prescribe anything," that we've kind of gone overboard and we need to be really careful about that. People still need treatment for pain, just in a thoughtful way.

 

Dr. Sheffield: Yeah, I agree. I think the pendulum has swung really far and for new providers coming out of practice, it's confusing because, you can get black and white and you can say these medications are bad, people that use these medications are bad people. And nothing's black and white like that in medical practice. And I agree. I think we need to treat pain in effective ways, but we can still use all the tools in our toolkit without causing harm.

 

Dr. Schneider: Yeah, I agree. Well, thank you, Pam, for joining me. This has been really very pleasurable and important topic to go over.

 

Dr. Sheffield: Thank you.

Dr. Seth Feuerstein: The only cause of death that's more common is accidents, actually.

 

Dr. Daniel Kraft: Welcome to Healthy Conversations. I'm Dr. Daniel Kraft, and today, I'm in Healthy Conversations with Dr. Seth Feuerstein, the CEO of Oui Therapeutics. We've got a lot to talk about. So for the first time on Healthy Conversations, we're going to have the same guest for a two-part podcast. Today, we'll be talking about a topic that's been very much in the news and a bit exacerbated by the pandemic, suicide. And suicide kills more than 45,000 people in the US each year, a rate that's remained stubbornly high, even with efforts like the new national 988 hotline. So Seth, why do you think we haven't been able to really move the needle on suicide more?

 

Dr. Seth Feuerstein: It's one of the reasons I ended up spending most of my professional time on this issue. Suicide is a condition of the brain that's universal in societies around the world. So in some ways, it's more like diseases that can cause sudden death, like cardiac arrhythmias in some ways. And so, I doubt we'll ever completely get rid of it, but we could certainly do better. I think there are a variety of systemic issues, as well as misconceptions and preconceptions about suicide, that remain stubborn problems, in terms of bending the curve and shifting the curve and reducing the number of attempts and deaths. I've been really fortunate to have some of the best training one can have, to be on faculty at one of the best medical schools there is, and yet, I had some significant misconceptions and preconceptions about suicide, despite all of this and besides being trained as a psychiatrist, that I'm really undoing and relearning over the last seven or eight years, since I've decided to focus on this area.

 

Dr. Daniel Kraft: Certainly, it's one of the leading causes of death in younger folks. And you mentioned you had your own common misconceptions. What are the ones that you still see commonly across healthcare profession and maybe even in psychiatry specifically?

 

Dr. Seth Feuerstein: I'm going to start with some of those statistics, because they are really, really frightening. And I don't think we talk about them a lot, because we often feel we can't do a lot about them. So the CDC and other estimates indicate that approximately one and a half million people a year attempt suicide in the US, and somewhere between 12 and 15 or 20 million, it's really not entirely known, think about suicide, have what's called suicidal ideation. The only cause of death that's more common is accidents, actually. So suicide is the number one medical cause of death for people in their teens and twenties.

Suicide is the fourth leading cause of death for people in their thirties, forties, and fifties. And the thing that I started to conclude, as I reviewed the data, was that the suicidal state of the brain is a lot like the arrhythmia state of the heart. It's a relatively spontaneous period, where there's an elevated risk of sudden death. And if we think about attempts as potentially deadly events or cancer metastases, we can focus in on preventing those deadly events, which is proven to be a successful model in other diseases like cardiac and oncology diseases. Does that make sense, Daniel?

 

Dr. Daniel Kraft: Yeah, I think that's a good analogy. I think we've all known friends or even colleagues who may have been suicidal or even successfully concluded that we didn't have a clue of, didn't seem to be on that mental health trajectory, where anything seemed to be wrong. And are there ways to find those early equivalent of the atrial fibrillation or EKG that can pick up folks at risk, even when they don't outwardly seem to be?

 

Dr. Seth Feuerstein: There are, and we're getting better at that. And one of the reasons we don't generally actively look is that, if you speak to psychiatrists and other clinicians, they'll tell you they're not exactly sure what to do with the patients to reduce their risk once they identify them. If you went to your closest hospital and you said, "how many stroke patients did you see in the emergency room this past year?" Probably somebody in the hospital can say, "we saw X number of stroke patients in the emergency room last month and last year." Same with heart attacks, same with arrhythmias. If you said to them, "how many suicidal patients did you see in the emergency room?" They probably would not even know where to look. They're not thinking about this in the same way they think about other leading killers, even though it's actually a major cause of lost life years in the United States. And I think we have a long history in healthcare, when we know we can do something, we actively seek out those patients. When we're not sure if we can do something, we don't.

The truth is, most people who attempt and die by suicide do not have major depressive disorder. And you also mentioned heart disease. It's a really great analogy. Diseases like depression and bipolar, they're risk factors, but they're not directly causative. And if you look at the risk factors for things like cardiac arrhythmia, they're remarkably similar to the risk factors for suicide. The very best predictor of a cardiac arrhythmia is a previous cardiac arrhythmia, and the same is with suicide attempts. The very best predictor of a suicide attempt is a previous suicide attempt, and for every death, there are about 30 attempts in the United States.

 

Dr. Daniel Kraft: Thanks to the stigma of mental health, an attempt may not follow someone in their records, so that you can be proactive and on the outlook. Are there better ways to integrate that into our EMRs and workflow of all forms of clinicians, so that you've had a heads up, that maybe, even it was 10 years ago, someone had an attempt?

 

Dr. Seth Feuerstein: Generally speaking, people were not screening for this, so The Joint Commission took it upon itself to start to push that forward. The Joint Commission, in fact, about two years ago, first started encouraging and requiring hospitals to start to screen people for suicidality, and so, we're starting somewhere. As a system, we're getting better. There are outstanding researchers looking at all kinds of data sources to better predict what might lead to an attempt.

 

Dr. Daniel Kraft: Are there any sort of top elements that you'd recommend that we kind of put on our radar when we're even talking to our friends and family, let alone our patients, to sort of see those early signs or even the acute signs that often are commonly missed?

 

Dr. Seth Feuerstein: Suicide, in my experience, may make clinicians more uncomfortable than any other condition, and I think the first thing is related to stigma. A lot of clinicians and a lot of non-clinicians are uncomfortable talking about suicide. If we think about a suicidal state of the brain, as an arrhythmia like state in the heart, hopefully, it'll make it easier for clinicians to talk about it. I think people are nervous that, if they identify suicidality, they're not sure what to do with the patient, who to send that patient to. People get very nervous when they know a patient is suicidal, because an attempt or a death feels like something we should have been able to predict and it feels like something that we might get sued for, if it happens. The reality is, asking from a legal perspective is better than not asking, and while it may be human nature to avoid areas where we're uncomfortable, it's an area we really should embrace.

 

Dr. Daniel Kraft: Are there any kind of equivalents to the screening EKG or cholesterol measure that could give us earlier insights into who's at risk?

 

Dr. Seth Feuerstein: Absolutely. There's some researchers who've developed something called the Suicide Cognition Scale, which is doing a pretty good job at providing indicative looks at future risk for people who've been seen in psychiatric settings. There's a group at Harvard looking at a variety of digital biomarkers, as well as electronic medical record data. There's no doubt that the kind of data that can be captured digitally will revolutionize our ability to be more contemporaneous with the periods of that risk and the ability to intervene with people when they are at risk. No question.

 

Dr. Daniel Kraft: We're now in this era of digital biomarkers, voice is a biomarker that can pick up mental health or neurologic issues. Give us a little bit of a flavor of where things might get to be more specific.

 

Dr. Seth Feuerstein: Yeah. I've been doing digital psychiatry work for more than a decade, probably about 15 years now. It's interesting, I did a lot of genetics work before that. I believe that, what genomics and proteomics were to disease categories like oncology, software will be to the brain. The brain is essentially an information acquisition processing and distribution center. And so, if we can ping that information processing center, see how the brain and the body react to that ping, whether we're pinging it with software or applying something inside the body, like a drug, or from outside the body to inside, like transcranial magnetic stimulation, software is a tool that will allow us to gather tremendous amounts of useful data, to understand what is working, what's not working, and what can work better.

 

Dr. Daniel Kraft: In terms of precision psychiatry, are there different subtypes of suicidality? If we can measure those, might we subset those patients or folks at risk of being suicidal into different prevention and intervention realms?

 

Dr. Seth Feuerstein: This is a very insightful question, and it's absolutely true. There are some people who are chronically suicidal ideators, meaning they think about suicide a lot and they have little or no risk of ever having an attempt. There are some people who rarely ever think about suicidality, but when they do think about suicide, the risk of an attempt is very high. And there's an infinite number of gradations in between. What they share in common is that, at the moment when there's an attempt that might lead to death, there's an inability of the brain to function properly and to see another option. Broadly, they'll, almost universally, tell you they actually didn't want to die, but they just didn't see another option at the time. It really undermines a lot of what people normally say when they hear someone attempted or thought about suicide. "Why did they choose to do that?" The brain as something that's a sort of logic driven machine doesn't actually see something to get it past what's in front of it. It only sees the one choice. Does that make sense?

 

Dr. Daniel Kraft: Sure. So there are folks who have the underlying, let's say, back pain or arrhythmia or mental health issue, others that we seem to be surprised that they had a suicide attempt or unfortunately a successful one.

 

Dr. Seth Feuerstein: We need to think about suicidal ideation in the way we think about things like chronic back pain. I can have back pain all the time and have little or no risk of ever having a ruptured disc. Or I can rarely ever have back pain, but if I have it, I may have a ruptured disc almost immediately thereafter. It really depends on the situation. We know that people who aren't sleeping well are at increased risk. We know that you don't process information as well and you're more impulsive when you're not sleeping. At the same time, what you're texting to people, the types of language you use, what you hear in the tone of your voice, all of those data sources and many more are relevant to predicting risk.

 

Dr. Daniel Kraft: You've had a pretty amazing and very background undergrad at Cornell Medical and Law School from NYU. We won't hold your law degree against you. And you did your internship at residency at Yale, working on the faculty of the School of Medicine, but what really drove you to work on the issue of suicide?

 

Dr. Seth Feuerstein: Suicide had always befuddled me since I was a resident, because we were asked to make judgements about patients. But there really wasn't a tremendous amount of data in that. And then, even after we knew someone was at risk, there really wasn't clarity around what we could do to reduce that risk. And that's what I got focused on. One of the things that I get most excited about is working on tough problems. Reading a lot of the research that came across my desk on the topic pretty quickly made me realize that, even though I had been on faculty at a leading university in the department of psychiatry for more than a decade, I misunderstood. The second was I had had a pretty successful career leveraging software in healthcare and mental health care delivery and felt that some of the things that I had been fortunate to be successful in could be applied to suicide risk. And the third was that it was the most inefficient and most problematic area potentially in all of health care, that one could make a big dent in. And so, that was really attractive to me.

 

Dr. Daniel Kraft: I know you've done work with the military. There's definitely a pandemic of suicidality amongst service members, particularly those who often served overseas in challenging environments. Maybe touch on the PTSD side and some of these new emerging therapies that go outside of traditional, let's say, antidepressants and counseling.

 

Dr. Seth Feuerstein: Generally speaking, medications for psychiatric conditions per se have not been shown to reduce risk of suicide, even though they can improve your depression, for instance. PTSD is a risk factor. It's essentially a stressor on the organ, a very clear stressor. Any organ in your body can give way at any time, whether it's your liver, your kidney. You twist your knee fast enough and strong enough on the football field, your ACL can snap. And I think that's really the model we need to think about when we think about the stressors that people put on their brain. That can be me or you, statistically, Daniel. I don't actually know exactly how old you are, but I think we're both in that number four cause of death window. You and I are at a much higher risk of becoming suicidal than getting melanoma, but I don't think it even occurs to us to not put sunscreen on when we go to the beach.

We do it, because we think we're at risk and it can help us. The brain is the same. If we have a condition like PTSD, or somewhere else in our life, there's a stressor, we need to be realistic that it is the number four cause of death for us, regardless of where we sit. We can't envision it entering that suicidal mode, but it can happen. And when it happens, it doesn't mean that we're weaker. It's what happens when the organ misfires. It's not your fault. We just need to provide the resources and the tools to reduce that risk and also to treat your PTSD.

 

Dr. Daniel Kraft:I think it's a enlightening way to sort of frame it. I met Zak Williams, the son of Robin Williams, who's quite active in the mental health space, and he used a term that I hadn't heard before, which is sort of practicing mental health hygiene, whether it's mindfulness and meditation or optimizing sleep or social connection. What are those sort of ways that you can inoculate against bad mental health, but all the way to suicidality?

 

Dr. Seth Feuerstein: I think we all know that, if you take a solid week off from work, if you have that luxury or stop doing the things that stress your brain, you feel a lot better at the end of the week. Oncology is a great example. If you've ever lived through a cancer diagnosis, it very much feels to the patient, in many cases, like their options are narrowing. It's not that cancer patients want to die, but the outcomes that they face are very, very large. I think it was that 40% of patients who get diagnosed with cancer end up in bankruptcy, due to the result of the costs of their cancer treatment. So you're pulling yourself and your loved ones into bankruptcy with you. Think about the toll that that takes on the brain as an organ. What kind of options would I see? Now, couple that with lack of sleep, the medications from the treatment, and all of a sudden, you're loading up the brain with all kinds of trauma around which it needs to start to make decisions. And it really freezes up, in the same way your laptop might freeze up and stop functioning.

 

Dr. Daniel Kraft: Healthcare issues are the leading cause of bankruptcy in general in the US. Is there a difference in folks in the UK with NHS, where they have underlying insurance?

 

Dr. Seth Feuerstein: Suicide rates are higher in the US across many of these age groups than they are in the United Kingdom. We're seeing a new wave of companies focusing more on serious mental illness, diseases like schizophrenia and bipolar, and working with health insurers around that. When it comes to suicide, we had this phenomenon in the psychiatric system broadly, not just in digital health, where suicide patients are turned away. Nobody wants them. I think there's two reasons they generally are not wanted as new patients. One is the perceived liability risk, and the other is the feeling that they don't have good treatment options for them. It is the only leading killer without a prescription product available. So as a clinician, who's a prescriber, I don't have an option. That's one problem. The other is the interventions that have been proven to work, they're really like a subspecialty. But the system isn't structured around subspecialties within psychiatry. So for instance, in cardiology, if I have an arrhythmia, I might be sent to an electrophysiologist. Suicide is similar. The interventions are quite different than other interventions, in order to work to reduce suicide attempt risk.

 

Dr. Daniel Kraft: That's an interesting point. There certainly aren't suicidologists. If you were to wave your magic wand and you had more folks trained in this area, what are the sort of most effective tools that they could use, that sort of take folks at risk or who have had attempts and to have them fully recover?

 

Dr. Seth Feuerstein: In terms of reducing attempts, the first therapy to get wide recognition was called Dialectic Behavioral Therapy, or DBT. The challenge with DBT is it's extraordinarily costly and intensive. Patients typically go for at least several weeks and often several months of around the clock care with access to their clinicians at night via texts, and that showed modest reductions in attempts. The second category was a modified version of cognitive behavioral therapy, which is about three months in length. That's the one I got most interested in. It actually separated attempts from ideation. That was one important breakthrough. And the second is it focused on giving the patient control. So as clinicians, we were often scared to say, "look, you can manage this yourself." That feels uncomfortable for clinicians. But what these researchers showed that they can reduce suicide attempts by 60% or more by going through this very specific, very specialized therapy. If I could wave my magic wand, we'd have an unlimited number of clinicians doing this. The problem with that is twofold. I don't have a magic wand. And the second is the work is intensive.

 

Dr. Daniel Kraft: As we're sort of now three years into the COVID pandemic, we certainly mentioned earlier stressors that can build up, we certainly see some high profile cases of physicians taking their own lives. Any learnings from that?

 

Dr. Seth Feuerstein: I'm going to say something very simple. Figure out, even if you need to ask people you know, when and what are the things that cause you to be more irritable, to sleep less well, pull back from those things. And then, number two, turn off your cell phone. Every day, a couple hours before you go to bed, as hard as it sounds, leave your phone in another room when you go to bed. The digital bombardment of the brain from all the data I've seen is definitely an ongoing stressor, and everything will be fine 12 hours from now if you put your phone in airplane mode. I found for myself that that was an incredibly powerful thing. And just detach as often as you can.

 

Dr. Daniel Kraft: So doom scrolling Twitter before I go to bed is not a good idea. I need to act on that myself.

 

Dr. Seth Feuerstein: That's a great interpretation of what I said.

 

Dr. Daniel Kraft: Well, thank you so much, Seth Feuerstein, for joining us on this issue of Healthy Conversations. A lot of insights and a lot of things to think about and hopefully take into our day-to-day life and practice. And we're happy to have you on our next segment. We'll be talking more about some of the emerging digital tools and digital therapeutics that can help prevent suicide. So hopefully, you are listening, will join us then, and thanks for joining us on this issue of Healthy Conversations.

Dr. Seth Feuerstein: So we can use software to tackle problems where we already have lots of prescription options, but life and death situations where we don't have good answers. The thing that really excites me is where can we use software to solve problems that were not previously solvable?

 

Dr. Daniel Kraft: Welcome to Healthy Conversations. I'm Dr. Daniel Kraft, and now we're in our second part of a two-part series with Dr. Seth Feuerstein, a psychiatrist, faculty at Yale, and the CEO of Oui Therapeutics. Seth, on our last conversation, we kind of covered the huge challenge of suicide and suicidality. Maybe if you can just give us a 30-second recap about what the problem state is in the US, around the world, and why it's so critical that we find new ways to address suicide.

 

Dr. Seth Feuerstein: Suicide is the number two cause of death in the US of people in their teens and their twenties. The number four cause of death for people in their thirties, forties, and fifties. It's the only leading cause of death without any prescription products, and it's a cause of death that's been increasing for a couple of decades. There's approximately one and a half million people a year with a suicide attempt and approximately 14 or 15 million a year who think about suicide without really good options that people can prescribe or offer their patients.

 

Dr. Daniel Kraft: Yeah, it has huge societal costs, and many of us who are health care providers don't often feel well-equipped to deal with those who have suicidal ideations or symptomatic suicidal behaviors. You've recently launched a company called Oui Therapeutics helping clinicians manage and treat these patients. Can you, first off, explain to us what is a digital therapeutic and how might it be used to replace or supplement more traditional therapies, particularly in the setting of mental health and suicide?

 

Dr. Seth Feuerstein: The phrase "digital therapeutic" is getting tossed around a lot these days. I like to be more specific and say "over-the-counter digital therapeutics" or "FDA approved digital therapeutics." So over-the-counter would be more like vitamins, things that are not regulated by the FDA that are essentially offered in combination with other products that's software and hardware driven to provide an intervention or a therapy in one way or another. Medical devices like pacemakers and hip implants, and drugs like the statins, or the antidepressants, or the antibiotics were the two categories before this.

FDA approved digital therapeutics is a new category in 2017. It was actually created by legislation and then the FDA implemented it, and this new set of rules created something called "software as a medical device" and essentially mandated that the FDA regulate this area and create this third leg of the stool, if you will.

 

Dr. Daniel Kraft: There's lots of consumer digital apps out there from smoking cessation to forms of mental health to exercise to managing almost any element of care. But to be FDA cleared, you have to bear a few hurdles. Can you help discern what those might be?

 

Dr. Seth Feuerstein: Generally speaking, it would be the same kind of thing that a drug might go through. I think toxicity is a little bit less of an issue for the most part with software as a medical device. The thing that really excites me is where can we use software to solve problems that were not previously solvable? So we can use software to tackle problems where we already have lots of prescription options, but life and death situations where we don't have good answers. And that's something that's really potentially breakthrough from my perspective and something really exciting to potentially work on.

 

Dr. Daniel Kraft: So let's dig into that. So your company, Oui Therapeutics, has created a tool for helping manage patients with suicidal ideation and beyond. How does the platform operate?

 

Dr. Seth Feuerstein: I had a lot of experience by chance early in my career. I founded a first generation digital therapy company back in 2009. Just for context, that was a time when, if things didn't work on your computer, that was because our DVD ROMs were scratched. That's how long ago that is in the software world. We scaled that to tens of millions of covered benefit lives. So from that experience we learned that patients do like interacting with software and, in this case, we made it apps that go on your smartphone. And patients interact with that, and there's a multidimensional interactive experience where you might work with a chatbot function, you might interact with other patients, you might work on practicing exercises to refine the way your brain might react to certain situations. And we combine all of those things into a multi-week experience that typically lasts about 10 to 12 weeks for a patient. They get offered it by a clinician, and they interact with it at their own pace over those two and a half months or so.

 

Dr. Daniel Kraft: Just maybe take that and dig down into a patient who's recently had a suicide attempt and they're now on the Oui platform. What do they actually do, and how does the clinician interact with that information?

 

Dr. Seth Feuerstein: In some ways it's like what they do when they're prescribed a drug. In other words, they get prescribed the app, they dose the app according to a schedule that they are told by the clinician, and then can follow through up on their own, which is similar to with a medication. I'd say some of the differences are that clinicians can check in, they can see what's happening, and they can interact with the patient. I would say more interaction is better. One of the nice things about it is that an app can remind them to do more and can learn from some of the information that they've entered to help nudge them along in certain ways. In terms of what's required of the clinician, really it's just to be a responsible and thoughtful steward of the experience.

I do think that in the future there'll be more ways to have more interaction with the clinicians. We want to make sure we're bringing them along on the journey so they can provide more useful tools. I will say an important part of this are the payers. We've had really good relationships and conversations with some payers including, for full transparency, the sponsor of this podcast. Payers do seem interested in allowing the right digital tools with the right data to be reimbursed and used with their health plan members. One way to think about it is the early days of the patient portal. It was not a good experience for patients, and so clinicians would send a message, patients had a hard time logging in. We're trying really hard to avoid that, and so we only want to require what's absolutely necessary for all the parties.

 

Dr. Daniel Kraft: For the patients, it's all about user interface that might be tuned to age, culture, language. What might a session look like on Oui Therapeutics' platform?

 

Dr. Seth Feuerstein: We're very mindful of that. There's no questions, some patients respond differently to different experiences, language, so we include different types of peer and group therapy type content that aligns with a diverse set of individuals. I might log in and I might be speaking with a chatbot, and that chatbot explains that they're going to guide me through a certain exercise. And in that exercise I might get to watch four or five other patients and pick one or two or all five of them and see what their experience was like doing that exercise, and then apply what they did to my own experience doing that exercise.

And what's interesting is some patients like to choose people who have had different experiences or look different to them, which helps them realize that, in fact, the experience that they're having is a more universal experience and not just limited to people like them. That's akin to what might happen in a good group therapy session.

 

Dr. Daniel Kraft: Got it. And as a digital therapeutic that you're trying to get through this FDA process, it's often still about comparing it to standard of care. So as I understand it, you have a design right now studying your intervention, comparing that to in-person therapy that had good results in reducing suicide attempts in military folks. Can you tell me about that study and how you find the methodology evolving?

 

Dr. Seth Feuerstein: We founded our company a lot like a biotechnology firm. We worked together to create a single software intervention that took the best assets from the very best interventions and put them in one place. The study you're referring to was published in 2015 and was actually launched a few years before that. So the researchers, what they showed was that just 12 doses of this digital therapy delivered over just a couple of months was far more impactful than all the treatment that these patients were receiving. So everyone in the control arm got everything. They got medications, they got therapy, they got inpatient, they got everything the system could throw at them.

But just 12 doses of this intervention, in that particular study, reduced suicide attempts by more than 60%. They estimated that they reduced, by more than six out of 10, the number of suicide attempts that were occurring in those populations over just a period of several months. They did follow up for almost two years, which is a very long time for follow up and found that the intervention seemed to have a bigger effect the longer you looked after only 12 doses.

 

Dr. Daniel Kraft: And are you digitizing that in-person type of intervention?

 

Dr. Seth Feuerstein: Yeah, so it's following up and layering in additional tools and resources, but that is a core part of what we do. The first data around the intervention was actually published in the Journal of the American Medical Association in 2005 by our team. And I think the thing that was shocking to me was that we could have an intervention that showed it was cutting potentially deadly events by more than half, and I couldn't find a single psychiatrist or psychologist, scanning across hundreds and believe it or not actually hundreds of thousands because I was at a national health insurer at that point after selling my first company. I couldn't find anyone doing this intervention.

That was a top five killer of groups of people in this country in different age cohorts, and there's something that can reduce their risk of a potentially deadly event by more than half and nobody's getting the intervention. That is a tragic situation, and it's fundamental to why we do what we do and what we built.

 

Dr. Daniel Kraft: And as you're building this, you've been able to develop separate tools for children, adolescents, and adults. How do you see the data and the interface shift?

 

Dr. Seth Feuerstein: There's no question, kids are different. The brain is still developing into your twenties, and what you expect when you're 15 is different than when you're 20. No question. They're still developing their ability to understand when their brain isn't functioning well and when stressors are really pushing them to the limit. They also need to go to adults very often to access interventions in care, but I think most of us can remember when we were teenagers communicating with the adults in our lives and especially our parents wasn't always that easy. We didn't necessarily have the words. We were scared because we were afraid how they might react.

So we're actually using software to create an adult support network around at-risk youth. The preliminary studies around which that software is based showed an 80% reduction in death among at-risk teenagers over 10 years from suicide as well as from accidental drug overdose and all violent deaths. And we believe that's because the software helped those adults understand how and when to communicate with those youth and vice versa when the youth can and should be communicating with the adults. They now had a more fluid way to access an intervention. And that intervention doesn't necessarily need to be a doctor and it doesn't necessarily need to be a treatment. It needs to be communication and rescue, essentially.

 

Dr. Daniel Kraft: That's super impactful. Of course you can't just prescribe the pill or the device. It's interacting with the socio and your family, friends, and community that often play a big role in outcomes. Have you seen any reluctance from providers or payers to think about this new digitally enabled mental health approach, and how might you address those misconceptions?

 

Dr. Seth Feuerstein: Innovation is a process, and so what we've seen is that, around suicide and around what we are doing, payers have been pretty receptive. They recognize that there aren't good options for their health plan members. They also recognize, if what we're doing works, it saves them a lot of money. There's no question that health insurers want to see good results. From Aetna and CVS, incredible support around the mission and the outcomes. The first large Blue Cross Blue Shield plan just announced full coverage of FDA approved digital therapeutics. We expect that trend will continue. In some ways what we are doing is specific, kind of like a new cancer treatment or for an orphan disease. It's something where there really aren't good options, and people do want to figure out how to cover that.

 

Dr. Daniel Kraft: And of course CMS drives a lot of this in terms of reimbursement codes and they have a new billing code, as I understand it, earlier this year. How does that change the game?

 

Dr. Seth Feuerstein: I think there are two ways that CMS will help drive success in this area. One is, as you mentioned, coding to pay for the digital interventions. The other is to provide reimbursement for clinicians to spend time with their patients around those digital interventions. And I think we'll see a trend from CMS and elsewhere where they're encouraging follow up and connectivity with their patients around treatments, around social determinants which will also help drive adoption.

 

Dr. Daniel Kraft: And are you seeing this ability to create digital health formularies not just for cardiovascular disease and diabetes, but now across mental health?

 

Dr. Seth Feuerstein: Absolutely. The first formularies that came up that received widespread attention were from CVS Caremark and Cigna Express Scripts. Those were largely over-the-counter digital tools. I think we're going to see them evolve where this is finally a place where value can really come into the prescription environment. I think there's been a lot of tension for a long time between the pharmaceutical industry and the payers around the value that each prescription brings in the drug world. One of the great things about software is we can collect a lot of data on outcomes and utilization, and I think payers want to pay for that. They just want to know what they're paying for. And digital provides a platform for them to do that through those formularies.

And I don't want to leave out employers. Suicide, when you think about the statistics I laid out at the beginning of our discussion today, if you look at any large employer, and large employers are usually at risk for the costs of their employees healthcare benefits, that means that suicide is a leading killer of their working population. Suicide is taking between five and 15% of all of their employee deaths. Think about that. Approximately one out of every 10 employee deaths is from suicide. Suicides are extremely costly to those employers, both from a loss of good personnel, spiritual wellbeing of the team, disruption in the workplace. They want to pay for that.

 

Dr. Daniel Kraft: Yeah, I think number one, of course there's always the reimbursement and regulatory challenges, but then there's also the challenges to get those solutions into the hands of clinicians and their patients and into the workflow without having to log into 12 different apps. Where are we on that paradigm?

 

Dr. Seth Feuerstein: It's tricky. I think in some large health systems, they've already selected certain platforms for certain problems that I would say generally lean towards low intensity, less sick patients. There are some platforms that have a half dozen or a dozen different interventions around mood, and sleep, and anxiety. I don't think it's clear yet what the right place of distribution and commercialization will be for these products. My guess is it'll come from a variety of places initially.

What I can say from my own experience is that patients are not the issue. Patients like the tools, they use the tools, they interact with the tools much more than they do with traditional office visits. The patients are not going to be the roadblock here.

 

Dr. Daniel Kraft: And so just to finish up with what you're doing with Oui Therapeutics, where are you now in this development process?

 

Dr. Seth Feuerstein: We have multiple products going through the FDA. We're optimistic that within a year or two, the first ones will be available to patients. We are actually working on some things that will not require FDA approval that should be helpful around suicide. More to come on those fronts.

 

Dr. Daniel Kraft: Fantastic. And just to close with putting our futurist hats on, if we were to jump forward 10 years, do you think, with these new emerging digital layers therapeutics, new forms of data, analytics, we can start to inoculate against the issue in the first place?

 

Dr. Seth Feuerstein: I don't know if we'll get to inoculation in 10 years, but I do think we may get closer to what we see for cancer, where we've got certain subtypes. Cancer is a whole group of diseases. I think the types of suicide risk are going to be one of those areas. And I think there are going to be some patients where we really can understand who they are in advance and almost completely eliminate their risk. I think there are going to be some cases where we can significantly reduce their risk, and then there are going to be some where we're still struggling. And that's where I think we'll be probably in eight to 10 years.

 

Dr. Daniel Kraft: And in my world of oncology, we now have the ability to sequence, sometimes multiple times, or look at the cancer stem cell protium. Hopefully this era, precision mental health will continue to unlock pieces in the neuroscience of the brain and hopefully being more proactive and preventative rather than waiting for the therapeutic component

 

Dr. Seth Feuerstein: I completely agree. I'm extremely excited for the next decade.

 

Dr. Daniel Kraft: Well, number one, thank you, Dr. Seth Feuerstein, for your amazing work in the space in the past and now and into the future. And thank you so much about sharing with us on Healthy Conversations. For those of you who are listening and you missed our initial episode, Dr. Feuerstein and I had a fascinating discussion diving into the etiology, the current state, and the challenges and opportunities to understand suicidal ideation, suicide in general, and to hopefully move the needle in that regard more broadly. So thanks for joining us on Healthy Conversations. We'll see you next time.

Pedro: Hi. I'm Pedro Centeno, psychologist and educational media lead at Safeside Prevention. Safeside provides suicide prevention, education and consultation to health and human services organizations. In this episode, you'll hear a wide ranging conversation about youth suicide. With three insightful and engaging individuals with different perspectives.

 

Pedro: Dr. Tony Pisani is a primary care psychologist and suicide prevention researcher at the University of Rochester Center for this study and prevention of suicide and the founder of Safeside Prevention, Ms. Christina Mossgraber is lead lived, experienced faculty at Safeside and the acting CEO of Nami Rochester. Dr. Melissa Dundas is a pediatrician and adolescent medicine specialist at NYU Langone Health and the Grossman's School of Medicine. This episode is full of practical advice and tips for providers. If you have any questions for any of our guests or would like to pursue suicide prevention education for you or your team, you can find episode notes and contact information@safesideprevention.com slash podcast. we'll get started.

 

Pedro: Tony, could you tell us how you got involved in suicide prevention?

 

Tony: I got involved in suicide prevention. Through tragedy really when I was, I was directing a family therapy clinic and also working in a primary care center. We had, uh, two people die by suicide in the course of three months, and that was very traumatic, of course, for the whole community, the families as well as the people.

 

Tony: Worked in the centers where I was working. And so I started to learn whatever I could, trying to catch us up on what's best practice, what should we be doing, and how can we better support people. And uh, I started to share what I was learning and then by sharing, I learned more. And that process just continued learning and sharing, and that continues up to today.

 

Pedro: Thank you, Tony. Christina, what got you involved in suicide prevention?

 

Christina: What got me involved in suicide prevention was the desire to give back after almost losing my life to suicide. I, about my gosh, eight years ago at this point, almost lost my life. I did not know that I was struggling. I didn't know that I really could have asked for help, and I had so much kind of fear and shame and just all these things a lot of people struggle with.

 

Christina: And then when I started navigating the behavioral health system, I found a lot of challenges. And so once. Stronger and farther along in my recovery. I really decided that I wanted to use that experience to, to give back to people and to be part of the change, and be part of help and to use this voice that I have, the voice of lived experience to say, okay, can get better.

 

Christina: You can live your best life. Recovery is possible. Your mental illness or your suicidal thoughts or struggles don't define you. They don't make you who you are and I started volunteering and doing some things, and I was on an advisory committee at our medical center, which is how I met Tony through that. He had a friend who has led that committee and she said, we've got this great program, this great person looking for lived experience, collaborator, and we had lunch and I saw the framework and I said, yeah, I, yes, and the rest is history as they say.

 

Tony: That was pretty great. Pretty great day.

 

Christina: It was. good food too.

 

Pedro: Awesome. Thank you. Dr. Dundas, how did you become involved in suicide prevention?

 

Melissa: Thank you so much for having me here. It's been a really interesting journey, be able to become involved with suicide prevention as a pediatrician and adolescent medicine specialist, part of our formal training doesn't encompass suicide prevention and really how to ask those questions, how to format visits, how to support patients and their caregivers.

 

Melissa: And so while I was a fellow at the University of Rochester, Tony had actually found me and we collaborated on a previous project, which actually gave me more education with regards to this area.

 

Pedro: Fantastic, thank you. Today we're going to be talking about a few major topics here that pertain to suicide prevention, but also as they relate to working with youth and doing all of this work in a healthcare setting as well.

 

Pedro: Dr. Dunes, could you tell us what is one of the most important elements when addressing suicide concerns with youth?

 

Melissa: Absolutely. I would say the number one thing is to actually really establish rapport with youth. It might be an area that they're not comfortable speaking about. They have been told not to talk about it, and when they come into our space, we really wanna center them and let them know, this is your space, this is your journey.

 

Melissa: I'm here to listen. And then build that form of trust with them. It just gives them that opportunity to really be able to discuss what's going on.

 

Tony: Yeah, and I think that can be really hard when you're asking these kinds of questions. Melissa, you ask all kinds of questions of youth that are uncomfortable, I'm sure, but they're all uncomfortable in a different way.

 

Tony: Yes. For this one, I can share some ideas, but I'm just wondering what your thoughts are about how do you address this particular topic, how you would typically bring it up, and we can then chime in on our thoughts.

 

Melissa: No, absolutely. So I tend to use what I call a graduation process. So I start off with saying, how are you today?

 

Melissa: How were you the last couple of days? How have you felt the last couple of weeks? And so it's not this right off the bat asking them, are you having thoughts about wanting to end your life? Are you having suicidal thoughts? Because with teens and youth, that might come off as too much to start off and they may not feel like they can connect with you.

 

Melissa: So I like to start just very soft with them and then lead into that specific question.

 

Tony: That's really interesting. Yeah, I think that's true of adults too, actually. Sounds, I think it depends. Our own comfort, like some providers need more of a ramp in just to feel comfortable bringing it up. And then some, and some patients need more of a ramp in, even when somebody's coming already, maybe expressing other kinds of distress or depression.

 

Tony: One, one phrase, I sometimes say, well, how bad has it gotten? And then maybe asking, has it ever gotten so bad that you've actually thought about ending your life? Moving it into that way that it makes the question pain thermometer question I'm under. I'm expressing by the way I'm asking it. I'm telling you I understand that that suicide is about things feeling really bad isn't just a question I'm asking. For me. This is a question because I want to know your experience. Yeah.

 

Christina: Yeah, I would. I definitely, it's interesting cuz from my perspective of both working with folks and being a patient or former patient myself, I even think about with my primary care physician who got to know me really well, that even when I knew she had to ask about it, I would get anxious.

 

Christina: I could feel myself really, even with relationship we had, are you just, it's a comf, it's an uncomfortable topic. Even living in this space, it can be really tough, you know?

 

Tony: Yeah. What was, what would make you feel nervous?

 

Christina: You know what's interesting is just, I think, and it's not that way anymore. It's dissipated.

 

Christina: Yeah. You know, but I think especially when I was earlier in my recovery or when I, I, I think I felt very vulnerable, but I think whenever would feel vulnerable, things can feel a little bit scary. And I think I just felt that feeling of like almost, oh gosh, what if I say the wrong thing when she asks?

 

Christina: Mm-hmm. Yeah. And I think a lot of times, especially with our youth too, they're worried about. What if I say the wrong thing, what’s going to happen?

 

Tony: Right. Who's gonna know? Is this gonna get, is this gonna get outta my hands? Yep. Exactly right. Cause we have a system where that's a legitimate concern, right?

 

Tony: Mm-hmm. And some, sometimes with good and important reasons, we need to take steps that are more. Kind of increasing the intensity, but other times there's also times where maybe we didn't need to, but people do move to coercive kinds of things and getting emergency services involved. Mm-hmm. When maybe that could have been handled another way, if the person felt more skilled and confident in being able to understand and respond.

 

Melissa: That's particularly important with youth as well, because some youth may not understand the true definition of suicide, and so some individuals, if they're having a really tough day, may make comments that allude to that, but that's not actually what they're thinking of doing. And so.

 

Melissa: That's why from my perspective, doing that gradual process gives the youth an opportunity to explain truly how they're feeling. So that again, you don't get all of these emergency services involved right there and then that can spook the child. They lose trust in us, never talk to us ever again.

 

Tony: Yeah, that's a really interesting part, especially with much younger kids.

 

Tony: Mm-hmm. And so what we've been seeing over the past several years is, You know, ages of kids that we previously would've said, well, suicide almost never happens. We're starting to see, unfortunately in the youngest cohort of kids, those rates going up. And I actually have a colleague at the University of Rochester, Ariel Shetal, who is specifically focusing on these younger, because we know very little about those youngest.

 

Tony: Sure. Those youngest. Children, but younger than 12 years old even, who are really expressing these kinds of things. Yeah. And she's especially focused on black children and youth where the research is even less. So she's really focused on kind of a doubly important area and it would be useful to probably talk with her at some point like this as well.

 

Melissa: Yeah, definitely.

 

Tony: But when it comes to the asking those questions, uh, we've made a lot of progress in our field. Instituting standardized screening, and I think it's hard to talk about connection without talking about how does screening occur and how does it go wrong?

 

Tony: What are, what you all, what your kind of experiences are with that. But screening is, it's helpful. We, if we don't have, as part of our routines asking these questions, we're all gonna avoid them. Sure. But what maybe, what are some of the things that we can think of to make sure that's helpful and not harmful.

 

Christina: I'll jump in Melissa, if that's okay. And um.

 

Melissa: Absolutely.

 

Christina: Yeah. As you're saying that, Tony, all I can think about is having been in an office where someone is clearly they're reading the questions off the screen or knows them by heart and is just typing them in and there's no response.

 

Christina: And I'm like, well, I don't, I'm not sure why you're even asking other than you have to, and when you feel like someone's just asking cuz they, they have. You're less likely to be honest and forthcoming because you don't feel a connection and you don't feel that they're actually really listening. It's funny cuz I'm, I'm an adult clearly, but I also have a, a mischievous like teenage side still about me.

 

Christina: Of course. No, yeah, not me. Never. And every once in a while, when that used to happen, I would be tempted to give an off the wall answer just to see if they'd even look up. I know that's my mischievous kiddo side still. It's funny cuz for me, I was thinking like, I wonder what would happen if I said something silly.

 

Christina: Not something to scare them, not something. I was just always honest, but, but it's interesting that sometimes that's what our brain does is it's just, I think for me, I was also trying to protect myself.

 

Tony: Yeah. So, yeah, no, it's hard because there are, especially in primary care, there are uh, uh, a thousand times a thousand requirements.

 

Tony: We don't know where to put something in public health. The first place we look is in primary care, cuz it's a place where we can access people. And so it's understandable that it goes and, but I think, I think sometimes we have to, we have to say, okay, in this very long list of things that we have to go through in a, in a flow chart of a medical record, what are the things that can go fast and what are the things that do need Yeah, that few extra, extra seconds or minutes to for sure to talk about or what are your, what do you think.

 

Melissa: Yeah, no, definitely. It is more common than I think we talk about where youth in particular may feel this inclination to not be honest with the first person who asks a set of questions. And typically that ends up being on the individual who may not be the medical person in the clinic. And then they get into our exam room, and then we ask those questions again.

 

Melissa: And so a lot of us outpatient and primary care are striving to educate everybody along that pathway, so they learn how to ask those questions. Even like your tone of voice can make a huge difference too. And just your body language. Christine, you had alluded to, if we're sitting there just typing and asking these really sensitive questions, if I was in that position, I probably wouldn't be inclined to answer them honestly too.

 

Melissa: So, Voice, intonation, intention, body language, all of that really plays into whether or not a child, a teen, a youth, is going to feel really forthcoming in that measure. But we do see that though.

 

Tony: Yeah. And one way, while keeping the pace that really needs to happen, one way to convey, let's say a nurse is rooming a patient within a healthcare setting, one way to do that is.

 

Tony: Maybe a short preface to the question saying something like, our whole team cares about your whole health, and I wanna ask you something cuz we really wanna understand your experiences. So I'm gonna ask you a couple of questions that may be sensitive, but we really want to know. Yeah. And then go into it.

 

Tony: No, I don't know. I didn't check the time on that. It's probably 10 or 15 extra seconds and that's not nothing when you have a lot of things to cover. But I think, I think as a healthcare we have to. Could it, might that be worth those extra seconds? Sure. To get, even if we only got 10% or 15% more openness, I think the cost benefit of an extra sentence or two might, might pay off.

 

Tony: Mm-hmm

 

Melissa: 100%. I would even go as far as saying that could be lifesaving, which is the goal of all of this.

 

Christina: Oh, absolutely, yeah. Sounds a lot better. Just to reflect on that. It sounds a lot better. Then I have to ask you these questions. Yeah, there was, what, one more sentence you added and it just sounds so much more inviting and caring and, yeah, genuine.

 

Tony: Actually, Pedro. Could you pull up the clip that we have of a nurse in a primary care setting in a telehealth setting, asking this question and bringing it up?

 

Pedro: Yeah, absolutely.

 

Pre-recorded clip with patient: Kayla, a nurse in a primary care practice is talking with Ms. Calderon, who scheduled a telehealth appointment, is a follow-up from a previous visit. In this practice, all patients are screened for a variety of physical and mental health concerns, including for suicide. Kayla has already asked some of those questions and is getting ready to ask Ms. Calderon about suicide. Knowing that these are sensitive questions, Kayla's asked Ms. Calderon if she has privacy to answer those questions and to let her know if that changes. Watch for how Kayla asks, with the goal of connecting and better understanding Ms. Calderon’s experiences.

 

Kayla: I'm glad your sinuses are better, but I'm sorry you haven't been able to sleep well. I'll make a note to the doctor. We care about every aspect of your health, including your emotional health. Are you okay if I ask you some questions?

 

Ms. Calderon: Okay.

 

Kayla: So the first question is, in the past few weeks have you wished you were dead?

 

Tony: We can stop there. So a couple things there, right? So one thing I we didn't talk about before was asking if the person's in a private place, a telehealth setting. That's really key. And then also asking permission.

 

Christina: Invitation. Yeah, that's exactly what I noticed too.

 

Tony: Now of course the first objection like you, you're going to hear is, well, what if she says no? I think it's sometimes we've been so trained to think a certain way about information that we forget that the validity of the information actually matters, not just the getting it.

 

Tony: Because if she says no, first of all, that's important information and that can be followed up on by itself. Person she was, she was not willing to answer these questions about suicide. Okay. That tells us something and we can, we already know more than we would have if we just asked questions and then,

 

Christina: Yeah, good point.

 

Tony: But also, If somebody's telling you no, then if you had asked them, they probably weren't gonna tell you the truth. Yeah, that's right. And so what's the point of having, we have to remember that the point of asking is to get data, and it's only good, it's only good to get data if it's good data.

 

Tony: And so that's, I think, pretty key and keeping that, that the, the connection is important for connection itself. Also, kinda like you said before, Molly, it's also important for get valid and reliable information.

 

Melissa: For sure. And I just, I love that. Ask for an invitation into that patient's space. Right? So it goes along with asking permission.

 

Melissa: Can I ask these questions? Yeah. Youth are very susceptible to that too. Like they have their own confines, they have that own space that they protect too. And so asking them for that invitation is just as important in pediatric care as it is in adult care, that as we saw in that video,

 

Christina: For sure. Yeah.

 

Tony: Yeah.

 

Tony: I, I think the one more thing that we can say about this kind of connection thing that, that Pedro asked about and that we've been talking about is if we remember that when we're, we use the word assessment and in, I, I think in the context of suicide assessment, really you could almost replace find and replace that with the word understanding.

 

Tony:. So if I say I wanna assess, say I want to understand a person's experience, not assess for a set of thoughts, and if we change it like that and we talk like that, so there's a set of questions I'd like to ask you to help me understand. People wanna be understood. Not everybody wants to be assessed.

 

Christina: That's right. Yeah. That’s 100%.

 

Tony: They probably really don't wanna be risk assessed. Exactly. Assess your risk. Now that's gonna, oh, is this gonna hurt? But, uh, is can, but most people do. If you say you wanna understand them, I'm up for that.

 

Christina: For sure. Yeah. Something that I use the phrase, help me understand. I can't tell you how many times a day in so many ways because if you just think about it.

 

Tony: Oh really. Oh, yea. Like in professional or personal space?

 

Christina: But you think about, to your point of people want to be understood and it's amazing how much more genuine, accurate information you can get when instead of perhaps going into a space of judgment or into a space of reactivity, maybe you just lead with, help me understand, you know, tell me more about that.

 

Tony: Ah that’s really interesting.

 

Tony: And no, it's really good. So it is, it's something that's a, probably a generally good skill. Mm-hmm. And then it's critical when it comes to something that people really don't wanna say. For sure. And this is, this can be one of those.

 

Pedro: Well, thinking about asking those questions and really trying to understand the person, this naturally takes us to a place of, well, if the person says yes, then what do we do?

 

Pedro: So we're faced with providing a response to that, to that concern, Tony, what are some good ways that you found that are really helpful to respond when suicide concerns are present?

 

Tony: Well, I think we wanna talk about what setting will make a difference. And I think here our context, talking with you here, Melissa, is in primary care, or at least healthcare in, in your case, you work mostly in adolescent medicine, but I know you've done a lot of, of, or in, in primary pediatrics as well.

 

Tony: I think the first thing to say about what to do is, is to remember that the, the set of options are more than a mental health referral. A lot of times primary care professionals have been referred to as gatekeepers, they're a gatekeeper to a mental health referral. Now, first of all right, you don't wanna be a gatekeeper, you wanna be a gate opener or whatever, right?

 

Tony: And that it makes it seem like your whole role is to identify and refer. Now a referral is important. Sure. And, but it's not the only thing that, the only helpful and potentially life-affirming thing that a primary care professional can do.

 

Melissa: No, absolutely. And it, and we have to remember too, that not all areas have access to mental health providers, referral resources.

 

Melissa: And so in primary care, oftentimes we are the first stop for somebody. And so when we think about what those next stops are, when an individual does endorse suicidal thoughts wanting to harm themselves, the first question we ask is, well, how do you feel right now? Do you feel safe in this moment?

 

Melissa: Second thing we try to do in pediatrics is who do you feel safe talking to? So thank you for involving me. But whoever you live with, is there somebody at home that you feel comfortable talking to them about? And then the next piece is, well, because you are a minor, you do have to share this information with the person that loves you so much at home.

 

Melissa: How do you wanna to do this? How do you want us to share that information? And I use the term US so that kids don't feel alone in that process. And then once we invite, whoever that loving human being is at their home is talk about can you keep them safe at home right now? What supports do you feel like you need?

 

Melissa: And then I will help connect you to those resources. And so it's not just a matter of us as the provider saying. Okay, you've told me this. Now I'm gonna open the gate and tell you where to go. Let me understand you, not just as the individual human you are, but as the contacts and the group and the home that you reside within, and what does the whole context of that living situation need and figuring out what to do next.

 

Tony: For some people where the home is not as safe a place. There's other people in the community, schools, teachers, and, and we can expand what we by supports. And even mostly you mentioned not everywhere has like access and availability to mental health. That's true.

 

Tony: But even where there is access and availability there's people that don't, many people don't want to go. Yeah. And if they do, it's often for a short time. And so we can't have our entire strategy. For suicide prevention when somebody presents in primary care, rely on that because no matter how, first of all, there's probably never gonna be enough behavioral health professionals to serve every single community, but even if there was it, people are usually in care for a pretty short time, but they remain in primary care.

 

Tony: So they've gone, and hopefully if us as behavioral health providers have our job, right? We've communicated back and we're working in close collaborations in some cases, and more and more there's actual co-location and integration, especially in more urban or metropolitan areas. That's great, but usually that will be for short time.

 

Tony: So what can do? So I think referring and also knowing where to refer in some, where it's available, there are more evidence-based suicide specific treatments than we've ever had, and maybe in a different conversation we can go. Depth about those.

 

Tony: But second, there are things that, that you can say and do that provide that support. I think some of the things that you just shared were like, you were speaking in a very collaborative way. You're, and I think, and another one can be to help the young person make sense of suicidal thoughts. Yeah. Cause yeah. Not everybody knows that. Oh, it's not that uncommon to have those thoughts, and it doesn't mean you have to act on them.

 

Tony: It's an important signal for us to listen to because it means that things are really bad, things are really hurting, but it doesn't mean that you have to do that or that you will do that, and we're gonna do whatever we can as a team to help you, not just not kill yourself, but, but we're gonna do everything we can as a team, so, You don't feel like you wanna do that.

 

Tony: Yeah. And another thing, so that's one is to help make sense of, of that, understand that as normal, but I think another is to offer the possibility that it actually can get better. Mm-hmm. We, we do know, we have quite a bit of research to say that if people engage, especially young people, engage with our teams and the kind of supports that we have.

 

Tony: And give it time, which can include a whole panoply of different kinds of treatments and interventions engage with it, with, with adults that they know they can feel better. And I can tell you, you know, many examples of that from my own life and practice and I can also show you a lot of research that shows people do get better, but we don't always let, we don't always let kids know that.

 

Tony: Yeah, no, you gotta be careful because we don't wanna say something that just feels like totally impossible to somebody sometimes. But I think sometimes we're so concerned about over-promising that we don't show any hope.

 

Christina: That's interesting. I think it's interesting to hear you to say, and every time I hear you say, and every time I hear when people say it, that I know that it's not uncommon for people to have thoughts of suicide, especially when they're struggling.

 

Christina: Their brain is in so much pain and, and when I share that with people, the people like, wait, what? That's, it's often surprising for people. I mean, it helps normalize the conversation when I'm having it with someone.

 

Tony: Cause they’ve been alone, like alone in it and thinking it's just me.

 

Christina: Exactly. They've been alone in it thinking it's just them and then thinking if they talked about it immediately there would, there would be a transport, there'd be intervention, there'd be EMS involved and it would escalate to a pretty traumatic situation. Yeah. But just to hear, everything going on in your life, it's not uncommon to have those thoughts, but it's an indicator to us that it's time to dig a little deeper and understand what might be going on, start feeling better.

 

Tony: And then I think we can, in, in addition to saying those helpful things, normalizing helping people put into context, offering some hope, those kinds of things then there's also plans that we can make. And that, that don't take a Behavioral health specialist to do, but so making plans for a person's safety.

 

Tony: Now there are different levels of doing that. There is an evidence-based intervention called the Safety Planning Intervention that has several steps to it, include the following up on, on these plans, helping a person identify their warning signs, things they can do to distract themselves, people they can go to, and sometimes in a primary care setting that, or certainly an emergency department setting, it can be challenging with time to do all of those steps.

 

Tony: We wanna aim toward that. And it might be that, that you have to say, Hey, we can just get started on this today, but I'd like you to come back on Tuesday and keep going with this. But I guess there's a couple things though that I would say, and I'm wonder what, what your common practice is with this, Melissa.

 

Tony: There's a couple of things that I would say to do, even if you can't go through an entire safety planning process, or maybe you don't yet have all of the training and skills or personnel to do that mean, I don't know. What would you. Maybe I could just ask you what's your practice in your setting, and then I can share what suggestions they have for, okay, if you could just do two things, what would they would be?

 

Melissa: Absolutely. So I can approach this from two very different points of view. Like one, having at one point in my life worked in a community hospital where we would schedule more close follow up and do some of those smaller portions to keep somebody safe.

 

Melissa: Versus being at an academic center where I do have access to social work in my clinic, I do have access to a psychologist who can be readily available once that assessment, that humanism, that rapport has been built to help coordinate what those next steps could be. But initially what I would do with, if I had a youth or a teenager in front of me is that I would again just understand the degree of safety concerns in that moment. Do they have access to our clinic numbers so they can call us even after hours if they're going through a period of distress? Do they have access to other national phone lines and do they have the ability to come back in a couple of days for a quick check-in?

 

Melissa: So I think those two things are like the simplest things that we can do that are actually really lifesaving in that moment. If we don't have extra things that we can provide them with.

 

Tony: I love that. I guess what I might add to that is addressing means safety and trying to find out what are one or two things that could happen in the person's life that could really send them for a loop. So in our framework we call those foreseeable changes. The idea behind foreseeable changes is that before the person leaves, I really would like to know maybe from the per, from the young person, from a family member, what are like a couple of things that if that happened, you would think, oh no, I am really worried about my daughter.

 

Tony: Or like, oh no, and finding out what those couple of Oh no things, and then you can then that can let you take the conversation to the next level. How likely are those to happen between now and when you're gonna be coming back, and is this something that's likely or not or unlikely? Do? Would we know if it happened or would we not?

 

Tony: Those are the kinds of things that can now get us into very concrete, so it's not just, okay, you know, what's a sign that you would know you were feeling bad? Well, those are good to do, but they're more general. This is like really nitty gritty could happen, that could really throw you off. And once you know that about a person, you can then begin to inquire about how predictable, how much visibility, how likely, and how soon is it to happen.

 

Tony: And then I think the other, in addition to identifying those foreseeable changes, as we call them, is addressing mean safety. What that refers to is to the extent that we can, trying to put distance between the person and the means that they might use to, to kill themselves. Yeah. Yeah. And the way I think about that is I'm looking in two places.

 

Tony: One, any means that this person has specifically mentioned before, and then two, any that are more common for that particular age group or culture. So I might think about those two things in terms of addressing those, because I would say of all the different public health interventions that we've had in suicide prevention, reducing access to the means when somebody is in the heat of that kind of suicidal crisis putting some distance between them and those means is, is probably the most effective one.

 

Tony: And we can't talk about that without talking about firearm safety. Pediatricians have really led the way in which, which really just, which really means that really figuring out how can we keep firearms in a safe location if you have them in your home?

 

Tony: And assume that the first two ways you would think of, the young person has already figured out. And then go from there. And it's, this is not, not to say anything about firearms in the home or any of that, but it's just that we know statistic that can make a suicide more likely. So if a, if you have a young person at risk, that's a really dangerous combination.

 

Tony: So you just wanna think it through. And then a couple of levels, a couple levels down. Yeah. I was just mentioning about different age groups and cultures, and that might be maybe a final really important topic. I know we only have a bit, uh, more time together today, Melissa and Christina. So I wonder if we should talk a little bit about that.

 

Tony: It's incredibly important about how do we address these concerns in a variety of different, of course, you can't cover every possible cultural group, but maybe just some that we work with. What are the things that have to, that sometimes need to be adjusted and how do we work with family members from different cultures?

 

Tony: And Melissa, I know that you're, you're there in New York City. And here in Rochester, we've got plenty of diversity as well. But you're really in the heart of migration, immigration, and all kinds of different melding of culture. So I wonder what your experiences are in that regard?

 

Melissa: No, definitely. I do wanna say that it is actually such a privilege to be amongst so many different cultures because that helps really educate clinicians in terms of how to just be even more generalizable and be able to connect with a multitude of different individuals from different backgrounds.

 

Melissa: But I would say from experience, the most important part is to understand what is somebody else's understanding of suicide and mental health. Right. I never wanna assume that somebody who has recently immigrated here for whatever reason, that we share the same understanding or the same context of what that means.

 

Melissa: And so again, that's like another invitation to say, Hey, can we talk about this? The next part that we really try to do is to de-stigmatize it and say that we don't really talk about it. I can say in my Caribbean culture, it's still very taboo to talk about suicide and mental health, but really saying that it's something that everybody from all shapes, sizes, gender, sexualities, races, experience.

 

Melissa: So how can I help you feel comfortable in this space so that we can talk about it together? And there's no judgment here. But you have to approach it with a sense of you can't paint everybody with the same brush, and once you can actually put yourself into that position, then it's actually quite, I wouldn't say easy, but it opens up that conversation to speak with individuals cross culturally and be able to treat everybody with the standard of care.

 

Tony: You mentioned not to assume that you have the same understanding. Probably true even within the same culture, but it's especially true across cultures. I was wondering, in your experience, what are a couple of areas where you've noticed there is that difference or disconnect?

 

Melissa: Absolutely. So individual's perceptions of struggle.

 

Melissa: So I've often encountered differences where, let's say I'm working with a family that may have been born and raised in the United States. They're from an affluent community. The child has everything they could possibly want, and the parents are thinking, well, my child can't possibly be having these thoughts or can't possibly be suicidal cuz they have everything under the sun.

 

Melissa: And it's, it's navigating that discourse and saying, well, sure, everybody can have all of these superficial things, but there's a disconnect somewhere for your child where they are suffering and it's okay to acknowledge that.

 

Melissa: And then there's other situations where, you know, with some of our migrant families who have really seen a lot more than any of us may see in our lifetime, may see that as the ultimate struggle and not necessarily the mental health component that either was there before, during that, or has resulted because of what they've gone through. And so it's really showing that irrespective of what your background is, this perception of, oh, this is a great struggle, or there's no struggle.

 

Melissa: Folks can still be struggling with suicidal thoughts, irrespective of those differences, and it's how do we bridge that to say those things actually at the end of the day don't matter. It's the individual person and their own internal struggle that we have to center in those conversations.

 

Tony: Yeah, that, that actually makes me think of another kind of reaction that people sometimes have, especially in very close knit families or cultures where the ties and like the kind of reciprocal ties and bonds are very important. I, I would actually even say that's in, in my own like kind of Italian American family that's true.

 

Tony: And it's probably true in other others as well. But I find myself sometimes having that same reaction, like when, like if somebody in my extended family is struggling, I'm, my first thought is, well, how could they do that to their parents? Or how could they do that to their sisters? And here I am, like, I'm supposed to be the psychologist. Oh yeah, I'm so open. No, yeah, great. He's gonna, he gonna be there for people.

 

Tony: But my, but within the context of own family. I sometimes have that kind of thing, like, how could you, or how could you say that? So I have a lot of, I have a lot of sympathy when I guess or empathy and identity or resonance with when a parent's first reaction is, how could you think that?

 

Tony: I get that. And we have to work with it. So not even though I also, another part of me cringes cuz it's like that's gonna totally shut the right, the young person down. But I also really understand it and I think that's, I think that's it is a key to working with parents and families if, cuz I think sometimes those of us who work with children and youth, we do that because we really like them.

 

Tony: And sometimes I have seen in some settings where it can get to this place where the kids, the hero and the family's the villain. And I think it's a really important to avoid that. And way you spoke before really avoids that. And I think that can be, can be really key to just realize it's not that easy.

 

Tony:. It's pretty hard to be a parent. It's pretty hard. Just people who are struggling. We have a member of our team who is a family carer. She's, she cared for her brother for a couple of decades with lots of, with suicide mental health, substance use concerns. And it's really hard.

 

Tony: And I think we can, I think if we go into those interactions, bring that, and then even though we probably in, in pediatrics or child psychology, we tend to, we're on the side of the, okay, that's why we love this. Yeah. Just making really sure that we don't even in our minds, kind of pit one against the other.

 

Tony: And realize adults, at least in general, are more likely to be supports. Even if they're not perfect, even if they say things like I do, um, can still be a valuable resource.

 

Melissa: No, definitely. And I think to your point there, Tony, we're all human at the end of the day, right? And that's why we all are, we're lifelong learners, right?

 

Melissa: And as long as we recognize that we ha we can have tendencies like that, we can act on them, right? One thing I have particularly found helpful with parents too, in that situation where some parents will be like, well, why is my child doing this to me? It's gently reminding folks that the child isn't choosing this and isn't choosing to feel this way.

 

Melissa: This isn't a choice, right? And at the end of the day, no toddler. Well, toddlers can be savage at times, but no toddler child, adolescent, youth, young adult wants to upset their parents. No one, like no child, wants to deliberately disappoint their parents. And I think when parents hear that, they really understand, okay, my child is suffering.

 

Melissa: This has nothing to do with me. Let me recenter this on my kid and get them the help that they need. And I think just like helping reframe that helps the parent understand that this isn't a choice. This is no different than diabetes or cancer or any other really terrible medical condition. We have to treat this the same.

 

Christina: I just wanted to, just gonna kinda reflect on what you just said, Melissa, what you'd been saying. Tony, and I've spent a lot of time working with kids in the schools and we would go through the warning signs, what to do, and definitely there'd be a young person who would say, okay, I heard what you said. I tried talking to my parent or my guardian, and they said, it's just teenage stuff.

 

Christina: You're just making it up. It's you're manipulative. He asked me all the time, do people talk about suicide as a cry for attention or cry for help. And I said yes, because they need help, right? Because they're hurting. And so I just really appreciate what, what both of you were saying, but just looking at it through the lens of, especially our young people, they don't always have the language and the tools and the understanding to verbalize what it is they need when they're struggling.

 

Christina: So sometimes these actions or behaviors that can be sometimes dismissed and misconstrued as the behavioral or as being manipulative or this and that. Like human, we're humans. And so.

 

Tony: Yeah. And I think that brings us full circle to why a primary care professional is not just a gatekeeper.

 

Christina: That's right.

 

Tony: Because it doesn't take a mental health professional to listen, understand and, and you can provide people with a different experience that's not nothing. Yeah. Might feel like something like, what can I offer? I'm not trained in this. What can I offer?

 

Tony: And, and I think that's, I think that's a, uh, maybe an important note to end on, that people across the healthcare spectrum have a lot to offer. More than just identifying and referring. There are things that we can do and say, and ways to listen can really make a difference. Yeah. Well, so thank you for having this conversation with you.

 

Melissa: It's great. It's so fun. This is really enriching.

 

Tony: I've learned a lot from this. And Pedro, thank you for hosting us.

 

Christina: Yes, Pedro, thank you.

 

Pedro: Absolutely.

 

Melissa: Thank you.

 

Pedro: It's my pleasure being at it again.

 

Pedro: All right. Thank you, Tony, Melissa, Christina. I've learned so much and it's been a really helpful conversation.

 

Pedro: If you listening, want more information, be sure to visit safeside prevention.com/podcast and you'll find information there about the safeside program and particularly those that are designed for primary care. So be in touch with us through our website and some of the episode notes that will be there will give some additional information as well.