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Chase: [00:00:06] Welcome to PsychEd the Psychiatry podcast for Medical Learners by Medical Learners. Today, we'll be taking a deeper dive into talking a bit more about suicide. It will cover additional topics relating to suicide risk assessment, suicide prevention and suicide epidemiology. Today, our guest expert is Dr. Juveria Zaheer. Dr. Zaheer is a clinician scientist with the Institute for Mental Health Policy Research, and she is also the medical head of the CAMH emergency department in Toronto, Ontario. She's also a assistant professor in the Department of Psychiatry at the University of Toronto. Her research integrates both population level investigations with qualitative research on an individual level to better understand mental health service delivery and service outcomes as it relates to suicide and psychiatric care. My name is Chase Thompson. I'm a fourth-year psychiatry resident at the University of Toronto, and I'll be hosting this episode. The learning objectives for this episode are as follows: One, develop an awareness of suicide risk and suicide prevalence as it pertains to the general population as well as psychiatric populations. Two, incorporate additional contextual information into suicide risk assessment that goes beyond SAD PERSONS or other list-based approaches. And three, develop a deeper understanding of how to approach and help individuals with suicidal thoughts and behaviours. Hope you enjoy the conversation.
Chase: [00:01:44] Thank you so much, Dr. Zahir, for joining us today and talking a little bit more about suicide. Just for our listeners, this episode is meant to build on some of the previous topics we've had in suicide, assessing suicide risk, as well as how to manage suicidal patients. But I think that it's important for us to have a little bit more of an in-depth conversation on this topic, given how often it comes up and how important it is to psychiatric practice. So thank you so much for joining us, and I'll just let you introduce yourself. I know you've been a frequent podcast guest at this point. I think this is your third interview, as we discussed earlier.
Dr. Juveria Zaheer: [00:02:28] Yeah. Thanks so much, Chase. My name is Juveria Zaheer, please call me Juveria. I am a psychiatrist at the Centre for Addiction and Mental Health in Toronto, Ontario. I am the emergency department medical head at CAMH. So we are the only standalone emergency department in Ontario and our goal is to provide ethical, evidence-based and dignified care to the people who walk through our doors. And I am also a clinician scientist and my program of research is focussed on suicide and suicide prevention, trying to understand the epidemiology of suicide, the lived experience of people with suicidal behaviour and to bring them together to co-create interventions that work.
Chase: [00:03:05] So I think one of the things that I wanted to touch on, you know, in this conversation is something that you spoke about in the previous conversation you had with us about: we tend to stratify individuals as low, medium or high suicide risk. But, you know, as trainees and residents working in the emergency department, sometimes it's hard, I think, for us to kind of have a more concrete idea of what that means. And we often don't really get taught about some of the statistics around suicide and the numbers or how often this actually happens. So I'm wondering if we could go through that a bit and kind of talk about suicide risk as it pertains to different populations in psychiatry.
Dr. Juveria Zaheer: [00:03:46] Yeah, I think that's a really important question because it's sort of like zooming out to see what the lay of the land is and then we can zoom in to make sure we understand a person's individual risk. So I think if you if you meet 100 people, probably 100 of them have been affected by suicide in some way. Suicide is the leading cause of death for young people and it is a top ten cause of death here in Canada. So when we think about what our rates of suicide, we often put them in person-years. So in Canada, we have 11 suicide deaths per 100,000 person-years, and person-years can feel a little bit tricky. But basically what it means is it's using, it's trying to account for the number of people that you're following and the length of time that you're following them. So I could follow a thousand people for one year and that would be 10,000 person-years. Or I could follow 100 people for ten years and it's the same amount of person-years. So we're looking at about 11 per 100,000 in Canada across the general population. And I know that one of the first things that medical students and residents are taught is that men die by suicide three times more often than women do, about 3.2 times more often in Canada, which is very consistent with other sort of white majority countries, European, North American countries. I think it's really important to point out, though, that women engage in non-fatal suicidal behaviour at a rate about 3 to 4 to 1, and that in itself is a really important treatment target and this gender ratio is quite culturally mediated. So in other parts of the world, that gender gap is much lower and up until about 15 years ago in China, women actually died by suicide more than men do and the rates there are about 50/50.
Dr. Juveria Zaheer: [00:05:24] And I think it's really important when we think about how we stratify risk or how we understand risk, to understand that there are certain things that are going to be more important than others. If you're a clinician and if you have a man or a woman sitting in front of you, the most important thing isn't their gender on an individual level, the most important thing is their history of suicidal behaviour or their current suicidal ideation, or whether they've been recently discharged from hospital. So, for example, in a in a psychiatric population and we consider that to be like anyone who has been admitted, say in the last year, you're looking at 500 suicide deaths per 100 000 person-years. And if we look at like closer discharge, so if you look at people who are discharged within the past week, it's close to 3000 per 100 000 person-years. So the closer you are to a discharge, the higher your risk is. And then I think an area that we don't talk about too much that can be quite frightening and dramatic for folks, for families and for patients and for care providers is that people do die by suicide in hospital. And so one out of every 600 or so psychiatric admissions can end in a suicide death in hospital but it's really important to point out that environmental factors, programmatic factors are so important and this is a really important area where we could reduce suicide risk and there's a lot of variability within institutions based on the kind of care that's provided and the kind of environment that you're looking at.
Chase: [00:06:46] Right. And I know you had mentioned that the gender gap in suicide rate is actually quite culturally mediated. I know you've done some work in this area, and I'm wondering if you could speak to the kind of anomaly that China represented where they didn't have that same gender gap that we see in North American culture?
Dr. Juveria Zaheer: [00:07:05] Yeah absolutely.
Chase: [00:07:06] Do you know what's going on there?
Dr. Juveria Zaheer: [00:07:07] Yeah, I think it's a really big and a really important question, especially when we live in a place like Canada that's so diverse and we know that, for example, my background is Indian Muslim, and although I was born in Canada, my risk is actually more similar to an Indian woman living in India for at least 2 or 3 generations and so understanding suicide risk in different cultures can be really important in prevention. And so, you know, classically when we formulate suicide, so people like Durkheim, Emile Durkheim, who was a sociologist, talked about how only men have the sort of the strength and the decision-making ability to die by suicide. And so it's the idea that non-fatal suicidal behaviour then culturally becomes something that a woman does and death by suicide is something that a man does. And these cultural scripts are so important because for a man who's suffering, who may be socially isolated or who may be not engaging in mental health care, it becomes a script that that makes sense to them and that's really important in suicide prevention. In China, though, up until, you know, the 90s and the 2000s, like psychiatry, is a relatively new discipline and suicide often didn't show up in psychiatry or neurology textbooks. It was more of a behaviour, it was an act of a powerless person in a very difficult situation. And the other thing to to point out around Chinese women in particular is the gender gap where women are dying more often than men is often seen in rural areas because women often engage in the consumption of poison, so rat poison, agricultural poison. And when you, those can be very fatal and so there's if you have an impulsive overdose attempt, for example, the risk of death is quite high. And there's a beautiful quote from some sociological work in China that said, 'when somebody dies of suicide, we don't ask why, we ask who is to blame'. And so we sort of start to see how important culture, gender construction of suicide is in suicide prevention.
Chase: [00:08:58] And the other thing that stood out to me about what you said, you know, when we're talking about the population of individuals who's recently discharged from hospital, the number I think was 3000 suicide deaths per 100,000 person-years, which, you know, is almost 300 times population-based rate. You know, I guess that kind of brings up other issues. Like one might look at that number and think, are we discharging patients too early or what is, is there some sort of lack of risk assessment going on at the discharge period? Or how do you understand that sort of really high risk period right after discharge?
Dr. Juveria Zaheer: [00:09:41] For sure, and I think what you're speaking to is can we develop a sense of therapeutic nihilism that our interventions don't work or our hospitalisation, which is often like the biggest card in your deck for acute care psychiatrist, doesn't work. I think another way of framing it is is a way of trying to be optimistic about the fact that we have a population of people that we know are high risk that we can identify. Often we don't know who's at risk and, you know, in the general community. So is this a place where we can act? And, you know, epidemiological data tells us what's happening. It often doesn't tell us why. And so the other half of my work is qualitative, where we interview people about their lived experiences. And one of the things we've just done, we're doing a study right now where we've interviewed all told 70 people, people who have lived experience of suicidal behaviour, who've been admitted, their family members, care providers. And what keeps coming up in that study is that you're in so much distress, you're in so much pain, you go into a hospital, you get support, you get the right treatment, and when you're discharged, your level of care goes from 100 often to zero. There's a really important paper authored by Paul Kurdyak, who's one of my colleagues, that says in Ontario 68% of people who have a suicide attempt don't have follow up within a month. And so I think as a system, we really need to think about intensive access to care in that post discharge period. So there are things that can work like close-contact follow up, so calling or following up with a person within 24 hours of discharge, higher intensity things than just offering an appointment. So can we meet someone on the inpatient unit, even start psychotherapy with them, have them discharged to the same provider? So I don't necessarily think that it's because hospitalisation doesn't work or that we're necessarily doing something wrong in that piece. I think in all of health care, transitions are so important and cardiac care, if you have an MI, then you go to cardiac rehab and trying to figure out in mental health care, how we can sort of honour the suffering of the people that we're serving and make sure that we don't go from 100 to 0.
Chase: [00:11:37] Right. Makes sense.
Dr. Juveria Zaheer: [00:11:38] And I think and I think the other piece is that, you know, epidemiologically, we're selecting for a very, very sick population. And I think anyone who has you know, it's an honour often to sit with someone on the worst day of their life and they tell you their story and they're in so much pain and you bring them into the hospital to help them. There's you see ten people you may admit two, and they are people who are very, very unwell and they're deserving of sort of very good in-patient care and then transitional care thereafter. And I think that's another piece of it.
Chase: [00:12:09] There's I guess, been some conjecture that potentially with the sort of deinstitutionalisation of psychiatry, the burden of suicide risk has actually kind of moved from, you know, the institution in the past, as we would call it, and now sort of exists more in the community. Do you think that's also plays into that part of the elevated risk in the post-discharge period or.
Dr. Juveria Zaheer: [00:12:35] Yeah, it's a it's a great question. We know that length of stay is a little bit shorter now, much shorter than it was back in the day and we know that very intensive services are less available. I do think, though, that one of the really important pieces around framing suicide prevention is it's not just a psychiatric issue. I think it's more about it's a public health issue and it has public health components, and that's food security, housing security, financial security and freedom from trauma and oppression. And I think as we see a bit of an unravelling of the social net where we see, you know, people who can't get a job out of high school and buy a house and, you know, have supports in that sense, I think that these broader social factors are really important as well. And so I think it's difficult to sort of understand deinstitutionalisation in context versus kind of the broader picture. And I think to a lot of people who are suffering from suicidal thoughts don't necessarily have the kind of mental illness that is severe enough for long term hospitalisation. So I think we always there's always that stuff that gets thrown around that 90% of people who die by suicide have major mental illness. That psychological autopsy studies are fairly flawed. And there's been some interesting work by the CDC and a nice paper in the New England Journal of Medicine that sort of talks about how the intensity of psychiatric symptoms are only one piece in risk prediction and things like relationship breakdown and conflict, things like housing insecurity, things like financial distress or trauma all play a huge role.
Chase: [00:14:06] So I kind of want to switch gears a little bit. So we have this sort of idea as residents and psychiatrists that, you know, one of our primary tasks is to assess suicide risk and to really kind of quantify the risk when we're presenting the case and charting that risk. But I think one of the things that I've learned from you in part, is that there's a lot of other factors about, you know the patient's wishes. What would be best for them in their certain scenario, whether that means hospitalisation or actually returning home and whether they're able to kind of participate in an outpatient plan that you put together for them. And I think you've also spoken about this on previous podcasts, but, you know, sometimes that means that patients who may have a higher, you know, quantitative risk, if we can say that would end up being discharged versus someone who might be lower risk being hospitalised. I just wanted to ask you, like, are there certain cases where, you know, even when an individual seems sort of reasonable, doesn't seem to have overt symptoms on the face of it, but the, you know, the plan you're sort of putting together seems good, but for whatever reason, you kind of have a bad feeling about the case, either from information you've gotten from family or from collateral, and in those cases, you're considering certification. I'm just wondering, like, how do you sort of approach those cases where the patient is actually presenting very well, but the family is very concerned and sort of saying, you know, well, if they go home, then I'm really worried what's going to happen to them, but there may not be like any sort of material evidence so far that the person is at risk.
Dr. Juveria Zaheer: [00:15:58] Yeah, I think that's a really excellent question, Chase. As an emergency department psychiatrist, I think one of the hardest sort of sets of cases you deal with is when there's conflict. In a perfect world, everybody is on the same page that I say to the patient, I think you're deserving of hope and help. The patient understands that and is hoping to come into hospital for initiation of treatment, and the family is on board as well. And as you say, when there's there's lack of consistency in that triangulation, it can feel very difficult. One of the things that I tell myself and I often share with patients and families, in obviously more appropriate language, is that admission to hospital in and of itself is not an evidence-based strategy for suicide prevention. There are things that we can do in hospital that can prevent suicide. For example, if someone's experiencing depression with psychosis, we can treat that psychosis, which would reduce someone's suicide risk considerably if that's what's driving the risk. If someone is intoxicated and having suicidal ideation in the context of that intoxication, holding and being able to sort of understand the person in context and safety plan thereafter would reduce their risk. And so I think that helps me sort of move beyond admission versus discharge. The question of and the other thing I say and I think I said this in our last podcast together as well, is if I'm working with someone and they want to be admitted, I should have a really compelling reason that I don't think that they should be admitted. And if I'm working with someone and they don't want to be admitted, I should have a really compelling reason for bringing them into hospital and engaging in what is trauma and what is quite carceral.
Dr. Juveria Zaheer: [00:17:28] And so the things that I sort of think about in terms of involuntary hospitalisation is trying to hold on to a thread of hope, if someone can hold on to a thread of hope and they want to be alive and they want to engage in care, then there's a lot that we can do to support them. So, for example, safety planning is an evidence-based intervention in suicide prevention. There's a lovely paper in JAMA Psychiatry that shows that we show a 50% reduction in suicidal behaviour post discharge if a safety plan is completed. So a red flag for me is if someone can't safety plan, if they say I have nothing to live for, I don't really I have no hope, I have no one to connect with, that makes me a little bit concerned. Things that can really affect someone's ability to plan or to not be impulsive make me really nervous. We did a study that showed that of people who die by suicide between the ages of 25 and 34 in Ontario, something like a fifth or a quarter of them have a diagnosis of schizophrenia. So for younger folks, having a psychotic disorder is a really big risk factor for suicide, and it's really treatable. Psychosis is treatable and psychosis hurts and bringing someone to hospital to manage that, if someone has psychosis, whether it's an affective psychosis, whether it's a primary psychotic disorder, postpartum psychosis is very high risk. These are people I tend to bring into the hospital because if you're not able, if you think about keeping yourself safe, the psychosis can really interfere with that. Around family work, I think one of the biggest principles in working with families is is radical genuineness and radical transparency. So to be honest and open about what we're thinking, I'll often say to a patient, I'm really worried about you. I'll say to a family, you know, I would really love to keep your loved one in hospital. I'm worried too, and not but, and, here are the limitations of the Mental Health Act. And so I think if somebody I think one of the dangers in risk assessment is say, if I see somebody and they had a very serious suicide attempt. They engaged in preparatory behaviour, so they wrote notes to their loved ones, they've been giving away their belongings, they have a very deep depression that is sort of characterised by decreased problem solving ability, a lot of pain and potentially even some psychotic symptoms and that person has an overdose attempt. They made efforts to seclude themselves, they happen to be found and they come in and they're sitting in front of you and they say, oh, everything's fine, I'm not suicidal anymore. One of the really important things to think about is like, what has changed between now and then? And for this person, not much has changed and there's very much that could be modified. And if you can come up with a way to keep that person safe, in hospital, can someone stay with them 24 over seven? Can we start treatment? Can they come to day hospital and be seen every day? Then you can kind of modify that risk. But if the person says, no, I'm done here, and you know that three months ago they were going to work every day and they were really active in parenting their children. And, you know, they have a family history where someone died by suicide in the same circumstances. That's a situation in which I would certainly certify. If you meet someone who, you know, brings themselves in, I have a very difficult time when someone brings themselves in for care and they're really honest about what they're going through, you know, that's a really good sign that they're able to engage and they're able to share with you what they need. And that's a it's kind of like the the door is open. There's a crack, there's a light where you can kind of connect with them and support them in that sense.
Chase: [00:20:48] For sure. Even sort of talking about, you know, the individual who's brought in by family, who's kind of concerned about suicidality. It sort of, even reminds me of when you see patients who are suffering with addictions and the family brings them in similarly and the person isn't kind of really ready to engage in that sort of care. And, you know, I think we understand that they need help at some level. And but at the same time, in terms of addiction and sometimes suicidality, the person is still kind of in that stage where they're not ready to engage with care or that can make it really hard too when you and the family are sort of on the opposite page as the patient.
Dr. Juveria Zaheer: [00:21:33] For sure, one of my colleagues, Gina Nicoll, who has dual expertise, she has lived experience with suicidal behaviour and is also does research with me, she says something really beautiful. She said, 'it's really important, not like not to just try to understand the plan, but to understand the pain behind the plan'. And so I think sometimes when people are feeling really ambivalent about living or dying or getting care or not getting care to try to focus maybe less on the plan and less on keeping someone safe and more on what's going on in your life that is so painful and what is driving it. Yvonne Bergman often says, one of her lines that is so moving, is when people want to die by suicide and you ask them what they want to end, they don't often say my life, they often say I'm exhausted or I'm a burden or I'm terrified. And sometimes connecting with that emotion and that feeling, it's almost like a motivational interviewing approach, as if we can connect with that person as a person, then it can help us understand how we can get at that underlying piece behind the work. And so I think there's some really interesting parallels with addictions as well. And I think any kind of tools that families have are really useful. In our work with families, so we've interviewed people who who've lost loved ones to suicide and who've supported loved ones in navigating the health care system. People don't necessarily often complain about like, I brought them to the hospital and they weren't admitted. They are really distressed about lack of communication, lack of open communication. They are really distressed about the differences between like confidentiality and safety, like that kind of space there. They get really distressed that the follow up plan makes no sense. Like, oh, you want me to follow up in three months? That doesn't make a lot of sense. And so I think there's instead of getting stuck on admission versus discharge, even with families, to sort of try to understand their concerns and context and try to do whatever we can to make sure that we have a safe discharge plan for someone and that we can help them engage in the supports they need. And if the person isn't ready, then that we have a plan in place that if they're ready, like can we like harness that moment and bring them into the hospital and do what we need to do at that point?
Chase: [00:23:37] Yeah. One thing you stressed is evidence-based care for patients with suicidality. And one of those things is completing a safety plan for that patient. I'm just wondering, is there any sort of particular, you know, diagnostic category that you might consider completing a safety plan, or are they really good for most patients who are having suicidal thoughts or behaviours?
Dr. Juveria Zaheer: [00:23:59] Yeah, I love that question. I talk about safety planning all day. So I think the old term that people often use to use is like contracting for safety. So like if I say like, you promise you're not going to do anything right, there's no evidence for that because you're not actually giving the person any support or skills in that moment. The cool thing about safety planning, you know, you talk about reasons for living. How do I distract myself? Who do I call to distract myself? Who do I call for support, resources that I can talk, I can contact and keeping my environment safe. So a little bit of means restriction in there. Every time you use the safety plan effectively, it's positively reinforcing, which is really, really cool. Although like safety plans aren't a panacea, like there's certain times where it's not going to work and timing is really important. So you mentioned around, I'll come back to the timing piece, but around diagnosis. Suicide safety planning is a pan diagnostic intervention, but there are certain people who may struggle with safety planning. So, for example, someone who's experiencing mania or psychosis, this may not be the right moment or the right time to engage in safety planning, although you can still engage in kind of a modified form of safety planning. We just had a meeting yesterday with our colleagues at the Adult Neurodevelopmental Service, and we talked about how do we adapt a safety plan for people with intellectual disabilities or people with autism. We're doing some research right now where we interview people about their views on safety plans. And so I think that's a really great place to start, is ask someone what do you think about this process? And if someone is like all in on it, then absolutely do it. If someone is kind of ambivalent, sit with them and show them. If someone is like, No, I've done it, this doesn't help me, find an alternative.
Dr. Juveria Zaheer: [00:25:32] The other piece that I mentioned earlier is around timing and safety planning. My colleague Gina often talks about waiting until the emotional bleeding has stopped. It can be extraordinarily invalidating, if I came to you in crisis and you were seeing me and I was saying that my relationship has broken down and I have been staring at a bottle of pills and I feel so alone and I'm not working, and you hand me a safety plan, you haven't even assessed me yet. A safety plan should be something that we come to collaboratively and we talk about the sort of striking while the iron is cold rather than trying to do the safety plan in the midst of crisis. I really like the idea of talking to folks about what works for them, and people are really good about about telling you. And I didn't realise until we started to do the research, but some people say to me, I prefer visual safety planning. Someone said to me once, I prefer a safety plan that's like a circle, so there's not an end to it. Some people say, like, I've been through this enough times that I can do it all in my head, and having a piece of paper isn't helpful. There's something at CAMH called the Hope App, which is really excellent. And for people who are like really good at the Internet, the app might feel a lot better. Often we ask who's important to you and we can photocopy the safety plan and give it to people that they love or give it to their care team too, which is really useful. One of the things I say is if you have like an iPhone, take a picture of it and then do the heart so it goes into your favourites so you can always find it easily. So I think that safety plans, again, they're not going to solve everybody's problems for sure, but they're sort of a tool in your arsenal that can be very helpful. And also it gives us kind of a shared language. So if my outpatient, for example, is struggling, they can say, you know, I've worked all the way through my safety plan and I know I need to come to hospital, and that's very useful and effective to know.
Chase: [00:27:15] I've definitely had the experience of being sort of an earlier trainee and bringing a safety plan to, I believe it was an older gentleman who was having suicidal thoughts, and he did find it to be quite invalidating to actually receive the plan and sort of fill it out with me. So I think I have sort of learned to ask as well if people find that helpful or appropriate or if they've done one in the past before, sort of jumping into completing one at this point.
Dr. Juveria Zaheer: [00:27:43] Yeah, absolutely. Like any time like it's we always talk about how like we always try to find the perfect question or the perfect thing to do, but it's not about the perfect thing to do, the perfect questions but the relationship. And so figuring out what the relationship, that's another Gina-ism. So figuring out what the relationship is is really, really useful and and reading the room before you start with one intervention or the other. And I think in in suicide-safe mental health care, choice is so important. Treating someone with dignity is really important. Not jumping to conclusions is important. Like if someone has been on Mirtazapine in the past and they hated it, then you probably would offer other choices. And so in the same in suicide safe care, if someone doesn't like doing a safety plan, is there something else that we could do that could be helpful?
Chase: [00:28:29] And just on the lines of evidence-based care for patients with suicidality. Are there other sort of treatments that we should be looking towards when a patient is having a high degree of suicidality, maybe across some diagnoses? We could talk about those a bit.
Dr. Juveria Zaheer: [00:28:46] Absolutely. I sort of think about suicide prevention strategies in four large buckets. So the first is how do we create a world where every life is worth living? And that means things like housing interventions, universal basic income, making sure that people are free from trauma and oppression, sort of like one bucket. How do we make the world a better and safer place? The second bucket is around understanding the treatment of underlying mental health issues. So we if somebody has depression, if somebody has schizophrenia, engaging in treatment for those for those illnesses. So we know that lithium, for example, is an evidence-based suicide prevention strategy for folks with mood disorders. We know that Clozapine is an evidence-based suicide prevention strategy for folks with psychotic disorders. So making sure that we know what the diagnosis is and then treating it. DBT, CBT, other types of psychotherapeutic interventions and antidepressants, not individually, they're not like lithium or clozapine, but as a class has level one evidence. Young people are really, really, really responsive to any kind of suicide prevention strategy. So any kind of sort of psychotherapy or higher term support for those young folks. And then the third bucket I think of is like public health interventions that are maybe more specific than the first bucket we talked about. So that's things like means restrictions. So gun control, lock boxes for poisons, bridge barriers that that kind of group of interventions, and then things like positive messaging around suicide and suicide safety in the media. So we think about the Werther effect where suicide can have a contagion effect. The opposite is the propaganda effect where we can talk about suicide in a safe way, show that there is care available and hope exists and help exists, that can be really important. Other types of interventions in that kind of bucket are things like gatekeeper education. So, for example, in the armed forces, if you can train like the generals and the corporals and the people who are kind of higher up to understand mental illness and to be open about it, it might make it easier for other people to get care. This works very well in schools as well, and religious institutions. And then primary physician knowledge and engagement, so like upscaling family docs and other care providers to be able to pick up on the signs of depression and suicidality. And then there's like this last bucket, which is kind of one that I'm really interested in, which is like specific interventions for suicide, often pan diagnostic. So the safety plan is one of them for sure. Another one of them that we're sort of trying to build evidence for is something called close contact follow up. So it's a little bit what we talked about earlier. So if you're getting discharged from an emerge or you're getting discharged from an inpatient unit, like someone will call you or reach out to you or you'll have like more intensive care in that period.
Dr. Juveria Zaheer: [00:31:26] There's also psychotherapies that are specifically designed for suicide prevention. So things like CAMS is a really effective treatment, DBT, CBT for suicidality, these sorts of interventions can be very useful. Family and patient psychoeducation can be very useful as well. And then individual means restriction, so like talking to people about safe prescribing. If someone is, a risk factor for someone for engaging in suicidal behaviour is alcohol, like getting the alcohol out of the house. If somebody is like feeling really unsafe around subways, like avoidance of those things. So it's kind of like safety plan adjacent, like trying to make your environment safe. And then we also, I think in the biological treatments we mentioned things like ECT, rTMS, ketamine, lots of new things with evidence building. So I think basically the principles are how do we create a world that's safe for folks both in terms of like both broadly and more narrowly? How do we make sure we treat the underlying illnesses that are raising suicide risk and reminding ourselves that mental illness is only one part of suicide prevention. And then the third, the last bucket is how do we engage in suicide safe care in terms of suicide specific interventions?
Chase: [00:32:39] And on the note of providing evidence-based care for patients with suicidality. I think sometimes, you know, we hear this sort of comment that like, oh, it's impossible to prevent or or we don't know that this particular intervention, including like SSRIs, even, is known to prevent suicide. And I think sometimes that can make one feel a little bit disenfranchised with some of the treatments we have. And are we even, you know, this patient's coming to me with suicidal thoughts and am I even helping them because I have this supervisor who told me this is this particular intervention has no evidence for reducing suicide. So I guess my question is like, you know, why is it so notoriously difficult to prove that our interventions are effective for reducing suicide? And and why do we have limited evidence on these?
Dr. Juveria Zaheer: [00:33:36] Yeah, absolutely. And as for like the Zaltzman paper that came out in 2016, it's a review in Lancet psychiatry and suicide prevention, SSRIs as a class do have level one evidence in preventing suicide. But you're absolutely right. It's not like I can link this prescription for Prozac with reduction in suicide deaths, because doing an RCT around suicide is very, very difficult because suicide is an extraordinarily rare outcome. So we often use proxy measures like suicidal ideation or suicide related behaviour. The other piece is that but even those aren't necessarily common, especially suicide related behaviour. The other thing is often in studies like people with suicidality are often excluded and so people think we're there too. Even for me, someone who does qualitative work, you know, you have to struggle with IRB to get approved, to even talk to folks who are experiencing suicidal ideation. And I think, too, like suicide is so multifactorial that one of the challenges in working with folks with suicidal ideation is that it's a complex problem that requires complex solutions. But there are interventions that work and hope and help exist. And I think to your initial point, I loved kind of hearing you describe that feeling as a trainee when you're sort of trying to navigate these two messages. So one message is that we can't prevent suicide. We get that in training. We have a terrible outcome and we reassure each other with this statement and it has its benefit in that it can help us feel better when something awful happens. It can be reassuring for families too, who did everything they could for their loved one. But it has, it's problematic in the sense like how do you, it can cause therapeutic nihilism. It can make us like not think as seriously about treating people who are really, really suffering. And then the second one is like, every suicide is preventable and that's lovely because we want to make sure that nobody dies of any kind of illness. And the goal of zero suicide and suicide, perfect care for people with suicidal ideation is so, so important. The problem with that, though, is that it can lead to a lot of distress in care providers and families. It can also lead to really bad outcomes like, are we just not going to see people who we think we can't help? Are we going to put everybody on a form one? It can be, it's really a tough kind of dichotomy to navigate. So like swinging between like therapeutic nihilism to like feeling awful about ourselves and our system.
Dr. Juveria Zaheer: [00:35:47] So for me, the way that I kind of the story that I tell myself is that like every suicide death is an extraordinary tragedy that affects families and care providers and the person whose life is cut short. And at the same time, suicidal ideation is a really important treatment target and people who are experiencing suicidal thoughts are deserving of hope and help, and we do have treatments and therapies that work. And so if it takes all of us to prevent suicide, I individually can't change the way the world is. We can advocate and we can be activists, but we can't change the whole world, but we can do our part. And that makes me feel better. And when I think when I do a suicide risk assessment, my goal is to make the person feel comfortable and safe. To say, I'm so glad you came, and like these these thoughts can often feel really shameful, but to say, like a lot of people have been through what you've been through and they've come through the other side. So stories of hope and recovery can be very useful for people, not in a toxic positivity kind of way, but in a natural and genuine way. And then once the person is feeling safe or more comfortable with you, then how can we understand their risk in context? How do we get all the answers to all the questions, understand their narrative of suicide, understand their risk factors, understand their protective factors, and work systematically to manage the risk factors and to strengthen the protective factors. And that's kind of the approach that I take. So it's less about prediction and most more about like best practices and providing good care. So if I see someone who has alcohol use disorder and when they use alcohol, it makes them at higher risk for suicide, we can do things like taking the alcohol out of the house. We can also help them enrol in addiction services, we can start them on naltrexone, we can introduce them to to other psychosocial rehabilitation models. And so if we can kind of link everything that the person is going through to their suicide risk as like making it higher or lower, and we can both address their suicide risk, but we can also decrease their suffering, which is ultimately the goal and have them live a life with meaning.
Chase: [00:37:41] Right. And I think one of the things, too, that I also came to understand is that, you know, saying that something doesn't have any evidence in preventing suicide doesn't mean that it has been proven not to have any benefit in preventing suicide. It's just that also that we don't have possibly the power of or powerful enough studies to kind of show the effects that we're looking for as well.
Dr. Juveria Zaheer: [00:38:07] Absolutely. And that's the challenge. So we know, if we can understand what the risk factors are across a broader population, then I think it makes sense that treating those individual risk factors can help. And I think the other really important piece is and this is like a plug for for qualitative research, is that understanding. There's no there's no like with like for us without us, right? Like there's no way of understanding someone's lived experience of suicidality and what helps and what doesn't unless we actually talk to folks and have them help us understand what's meaningful or not. So I think like engagement and co-creation is really, really valuable too in this population.
Chase: [00:38:45] So one thing that I think comes up in the emergency department quite often, and we have touched on this topic briefly in our borderline personality disorder episodes, but, you know, there's this, I guess, constant balance that we're trying to strike with some of our patients who have borderline personality. On the one hand, we are concerned about their safety and on the other hand, we're also told that we don't want to create sort of this situation where, you know, the individual comes to hospital and we make them feel safe in hospital and we sort of become a de facto coping mechanism for that individual. And I'm just kind of wondering, how do you balance that care for someone's safety and wanting to be validating, but at the same time sort of taking on the cruel to be kind sort of mantra that others have advocated for in terms of treating borderline personality.
Dr. Juveria Zaheer: [00:39:41] For sure. And the first thing I'll say around BPD is it's a diagnosis that does not have a ton of like construct validity in a sense. Like it's not a it's supposed to be a diagnosis that indicates like a lifetime, pervasive pattern of dysfunction. But we do know that a lot of people who are experiencing other types of major mental illness, particularly people who have a trauma history, can look like they have BPD, but that might not be the most appropriate diagnosis or it may be a comorbid diagnosis. So I think for me, one of the things that helps me is to move beyond like how do I treat someone with BPD to like, how do I use universal precautions from trauma at all times? And so many people who come to psychiatric emergency departments have a trauma history. Many people with BPD have trauma. Almost everyone with BPD has trauma, and the system and having suicidal ideation and behaviour is traumatic in and of itself. It's like threatened loss of life and threatened loss of integrity. And so for us at CAMH, and I think for me personally, it's like, well, how can I understand someone's story? How do I make them feel comfortable? How do I make them feel safe? How do I work with them to build safety and autonomy? I think one of the things that we do is if we have someone who is coming into hospital a lot, it's really important to look at their narrative arc of suicide risk. So, for example, if you have someone who is has come in eight times in the last month but hadn't come in in the three years before that, you know, a diagnosis of BPD or a formulation of 'we don't want to reinforce this behaviour' might not be the most accurate one because it could be that there's an episode of severe mental illness that we're just not treating all the way. If we know that someone is not doesn't get better in hospital or gets worse in hospital, I think it's really worth striking while the iron is cold again, having conversations with this person in the context of safety planning outside of the moments of crisis. There's a lovely paper by Von Bergmans and two of her former patients who have BPD that talk about how different I look when I'm not in crisis. And so if we can engage with people and we do this in the CAMH Emerge often as they engage with people when they're not in crisis with their care teams to figure out what exactly is most helpful in the moment. Sometimes what we do is we want to sort of it's kind of a I'm not a DBT expert by any means, but sort of taking we we live and work in a system where, like there's sometimes suicidality can be seen as a ticket to admission and if you don't endorse suicidality, then you can't get admitted. And so then it ends up that people have to up the ante to get the care that they need.
Dr. Juveria Zaheer: [00:42:15] And I often reflect on the word manipulative, right? Like we often use this. It's a very gendered word, first of all. And for someone like me, if I if I had like a loved one or if I myself was struggling, I could call like 100 people and they would help me, like get the care that I need. But that's an incredible privilege. And if you don't have that privilege, all you may have is the emergency department. And so I think, like we see somebody who has increased service utilisation, one of the strategies we use is to try to strike while the iron is cold. It is very difficult to safety plan or to identify one's feelings or needs when one is in distress. And so if we can work with a patient and their care team outside of crisis, then it can really help us understand what they may need when they are in crisis. For some of our patients, we try to get rid of that ticket to admission kind of construct. And so often in mental health care, it's you're admitted if you're suicidal, you're not admitted if you're not. And then the ante keeps getting upped. Well, you're only going to get admitted if you self-harm in the department, you're only going to get admitted if you have a serious suicide attempt. And so what we try to do is disentangle the reinforcement from the behaviour and to say things that we sometimes we do something called a green card strategy where someone can come into hospital for a set number of days, a set number of times in a six-month period. And we really validate and reassure and support people for coming in before their crisis. I think it's really important to remember that people with BPD do die by suicide and they often die by suicide after periods of intense service utilisation. And so coming into hospital to break that cycle can be very useful. We work when we when we bring people in, I think it's really important to identify goals of admission and so that can be really tough when someone is like really activated and struggling. But to say, you know, we'd like to bring you in, we'd like to review your medications, help you connect with family, try to arrange good follow up, which is part of the problem, right? Like if you go from everything to nothing, that's a huge problem. And I think trying to be open and transparent and honest about, here are our behavioural expectations, what are your expectations of us? What do we think this length of stay is going to be? When people have a lot of trauma, they can't predict their environment and even neutral stimuli can feel very frightening and threatening. So should try to be as as as reassuring and supportive and open as possible, I think is a nice approach. And again, like if I if I'm working with someone and I know that when they come into hospital, things don't get better and they probably know that too, I try to be really honest about it and try to problem solve. And I think the other thing I know you and I have talked about this even on call, where it's a lot easier to be empathic and kind when it's 11 a.m. on a Tuesday and you're just back from vacation than it is at 3 a.m. where there's a full waiting room with 15 people waiting and you haven't slept and you haven't eaten. And so I think for us, it's really important to reflect on our own ambivalence and our own distress and what we're bringing to the encounter, because it can it's a it's a bidirectional process, assessment. And so to be kind to ourselves as well and to check in with ourselves, before we work with folks who are also in crisis and struggling, can be very useful.
Chase: [00:45:20] Yeah. And you know, it also brings to mind sometimes I feel a bit disingenuous telling people, well, you know, the treatment for this is DBT and that's ideally what you should get on an outpatient basis. But in reality, you know, the person may not have any funds to access it and the wait times for publicly available DBT, you know, this is an Ontario based podcast, but I'm sure it's very similar no matter where you are, accessing DBT can be quite difficult. And so admission also becomes the fastest way to speak to someone who may be like first in DBT or able to kind of work with you on your distress tolerance in a really immediate sense.
Dr. Juveria Zaheer: [00:46:03] Yeah, absolutely. And I think that's not a bad indication for admission. I think we need to think about the failures in our system and to be really open and genuine about those failures and then thinking about ways that we can advocate for better access to trauma therapies and better access to DBT and we definitely can't do it alone for sure. And I think I really like what you said about like picking up on those moments of feeling disingenuous and to sort of say like, does the plan I'm giving this person actually make sense? Like in talking to patients in our studies, like I think they would rather hear from us like, look, here's the treatment and the waitlist is going to take a really long time. And I'm so sorry about that. And what can we do in the meantime to help you feel supported, whether that's, you know, an urgent care clinic or other types of support rather than DBT is the way to go, here's a list and then when they call everybody, they realise that nothing is open or available. So I think that that kind of that feeling that you have, that empathy for the person you're working with is so important.
Chase: [00:47:01] Wanted to get your thoughts on another topic that I think is becoming maybe more relevant as we move towards legislation for made for people with psychiatric illness. And this sort of revolves around the topic of involuntary hospitalisation for people who have suicidality or who have had suicide attempts. I guess I'm wondering how you sort of frame that or how you think about the ethics of involuntary hospitalisation for people who have suicidal thoughts or behaviours.
Dr. Juveria Zaheer: [00:47:37] Then starting with the involuntary hospitalisation piece, I think psychiatry is facing a reckoning of sorts where we have to come to terms with our own history of oppression. We need to come to terms with our own systemic racism and anti-black and anti-indigenous racism specifically. We also need to come to terms with the fact that we are how we are the third arm of the law in many ways. We are carceral and so part of this sort of process needs to be understanding the power that we have and needing to understand the experience that people who are being held involuntarily are having. So for me, I think it's really important. There's a few things that I do to help myself understand the ethics of this. I think, as I said earlier, if I'm going to bring someone into hospital involuntarily, I better have a very good reason for it and I better be able to describe that rationale to the person I'm working with. Here's what I'm worried about. And for someone with suicidality to be very clear that it's not a punishment, that these are the goals for you coming in, whether it's collecting more information or providing support or whatever it is. I think that's really, really important.
Dr. Juveria Zaheer: [00:48:46] And I think one of the things that is really helpful around forms and certification is to actually speak with the person about it, asking about past experiences of certification, asking about what it means to them. Like I have people who I say, I'll say, I'm so worried about you and I'm worried that if you were to leave here, you would continue to suffer and your life would be at risk and I think that we can help you here in the hospital. But I also know that being held involuntarily is really traumatic. What are your thoughts? And then people, you have these really interesting discussions about some people will say, you know what, I'd like to come in voluntarily and being formed would be really awful. Other people have said to me, the act of being put on the form is reassuring to me because it shows me that people care about me and I don't, sometimes when the thoughts get really dark, I don't trust myself and so I understand. Other people say, I don't like this, but I know it'll make my family feel better. And so actually having that conversation can be very useful. And I think like owning what we're doing is really, really important.
Chase: [00:49:56] So I know we've taken up a lot of your time already, but I just wanted to get your thoughts on what do you think the future holds for suicide prevention and suicide treatment?
Dr. Juveria Zaheer: [00:50:08] I was reflecting. I was doing teaching for our first year residents yesterday, Gina and I were. And we often ask people like, when was the first time you ever heard about suicide? Like when you were a kid? Like, what was what were those conversations like in your family? And the answers are so thoughtful and meaningful and so sad in some cases. And I feel badly, I'm the kind of person who never thought they would always talk about their kids, but I always talk about my kids. And I have an eight-year-old and a three-year-old and, you know, in my family, we were a muslim family, you know, suicide was haram. We never talked about suicide. We didn't even kind of understand it. And if it happened to someone else it was 'how could they do that to their family?' There wasn't an understanding of the mental health piece. And with my daughters, you know, we talk about how we're so happy that they feel well now and there's going to be things in their life that make them feel worried or scared or happy or sad. And sometimes sadness or worries can stick around even when good things are happening and they can make us not feel like ourselves and they can make us feel so sad and scared. And sometimes for some people they can even make us not want to be alive anymore and if that ever happens to you, we're always here and we'll figure it out together and people get better from this. And so I know it's like a long-winded way of saying, you know, when we think about the future of suicide prevention, it's not my eight-and three-year-old for sure, but I think it's like these conversations that's striking while the iron is cold. It's the work that's done by people like Jack.org. It's like changing the way we talk about suicide and making it easier for people to understand that there is hope and there is help and there are treatments that work.
Dr. Juveria Zaheer: [00:51:39] I think, when I think about the future of suicide prevention in terms of research, I really do think that the future of suicide research is in co-creation and working with people to develop interventions for communities that work and then to test those interventions. And the future of suicide prevention is around accessibility and availability of evidence-based treatment. As you say, we have really good treatments that work, and universal health care means universal access and equitable access. And I'm really interested again in these kind of like suicide specific interventions that that we might not think of because we always think about like diagnostic silos, but I think that's really exciting. And I think the last piece is, is how do we go back to creating a world where every life feels worth living and how do we invest in social cohesion and a social net and freedom from the stressors that make us feel really scared and worried. And I think a lot about gender and race and how we, like the cultural scripts of how we act. So how do we encourage white middle-aged men in rural communities to get care? How do we make sure that people from indigenous communities have clean water and freedom from trauma and have ways to tell their stories in ways that matter? And I think that's what suicide prevention looks like to me.
Chase: [00:52:54] Thank you so much Juveria for joining us today. We really appreciate having you on the podcast. Your answers were incredibly insightful and always helpful in guiding how we think about suicide as trainees and helping us move forward beyond risk assessments. So thank you so much. Did you have any final comments or any words of advice for our listeners?
Dr. Juveria Zaheer: [00:53:17] I think what I would say is that we're you guys are really good at this, like you're good at talking to people about suicide. The more you do it, the better that you get and don't ever think that the checklist is more important than your humanity. You need to learn the checklist; you need to make sure that you're thorough and you create a plan that works for people but the thing that people are going to remember about you is your humanity and your kindness and your openness.
Chase: [00:53:42] Thanks for listening. We hope you found our conversation informative and enjoyable. PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and recorded by myself, Chase Thompson and our theme song is Working Solutions by Olive Musique. You can contact us at Psychedpodcast@gmail.com or visit us at psychedpodcast.org. Thanks again for listening. Bye.