View episode transcript

Featured Guest

Cheryl King, Ph.D.

Objectives

• Differentiate the importance of assessing for suicidality and depression separately.
• Understand misconceptions about depression and suicide.
• Apply lethal means reduction strategies.

Resources

• Adaptive testing technologies (The CASSY) (Adaptive Testing Technologies)
• Risk factors, protective factors, and warning signs (American Foundation for Suicide Prevention)
• Turning a psychiatric crisis into a chance to prevent firearm injury
• Parents’ Guide to Home Firearm Safety (Injury Prevention Center)
• Prospective development and validation of the computerized adaptive screen for suicidal youth (JAMA)
• Ask Suicide-Screening Questions (ASQ) Toolkit (National Institute of Mental Health)
• Adolescent suicide risk screening: a secondary analysis of the SHIELD randomized clinical trial (Journal of Pediatrics)

Disclosures

Cheryl King, Ph.D. has disclosed a relevant financial relationship with:  Adaptive Testing Technologies - Intellectual Property/Royalties, Conflict is relevant but is managed.

This relationship is relevant, this company does work in the topic area. This relationship was managed by peer review and is free of commercial bias. 

CME

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Transcript

Dr. Christina Cwynar:

Hello and welcome to Breaking Down Mental Health. Today is a unique episode as both Dr. Burns and social worker Simon Khan are unable to join us. So, I'm honored to have a very special co-host, Dr. Cody Weston, a child and adolescent psychiatrist who works clinically in the psychiatric emergency room, the child adolescent inpatient unit, and the consult team with myself. He has interest in emergency psychiatry, outcome research, and behavioral mind body interventions. Thank you, Dr. Weston for joining me today for our discussion.

Dr. Cody Weston:

Thanks, Christina, for having me. I'm honored to be here. We are joined today by Dr. Cheryl King to discuss suicide in depression. Dr. King is a clinical child psychologist and professor in the Department of Psychiatry where she directs the Youth Depression and Suicide Prevention Program. Thanks for joining us today.

Dr. Cheryl King:

Thank you. This is an important topic and I'm happy to be here.

Dr. Cody Weston:

Thanks. So, Dr. King, why is it important for us to assess for both suicidality and depression?

Dr. Cheryl King:

Well, it is critically important to assess for both of these because that enables us to both take care of a youth safety or suicide risk if present, and to develop the most effective and implement the most effective treatments. Although suicidality or suicidal ideation and behavior, more generally, suicide risk often co-occur with depression, sometimes it's occurring with other conditions too. And whether it's the depression or the suicidality, we will want to develop specific treatments to target them. For instance, if suicide risk is present, of course, safety is a primary concern. High risk is not always present with depression and may be present without depression. And we have learned that even if it is present with depression, treating the depression may not reduce the suicide risk and the suicidal thoughts and behaviors. So, for instance, if we have suicide risk, we want to think about a treatment plan that has different components first.

What do we need to do more immediately in the short term? Is there high risk? Do we need to be watching this youth 24/7? Do we need to develop a safety plan of how the family will respond if they're feeling increasing warning signs or risk or distress? Do we need to hospitalize the youth because the risk is so severe? It's not realistic that a caregiver can really watch a youth, a teenager 24/7. So, we're thinking about our immediate steps, and then if there's suicide risk, we're thinking in the short term in our treatment plan, many of our treatments for depression and other conditions, they're not immediately effective. Our medications for depression be effective the next day or three days or five days when the youth is at high risk. Some of our cognitive behavioral or other therapies we're working on problems, changing patterns of thinking, patterns of behavior.

That's not changed because they've come in for one session. So, we have to think about in this intermediate period when yes, we're actively engaged in treatment with the youth and the family, but we're not naive in thinking it's already effective, what additional steps. Can we offer more sessions? Can the family offer more structure, routines, oversight? And then we're thinking ongoing with treatment what might be different with a treatment for a suicidal youth? So, we have things like creating a hope box, consistently revisiting and modifying the safety plan. So, there are some different interventions, and I think as is always true in mental health, behavioral health, the best treatment plans come from the most thoughtful assessments and formulations. So, we definitely want to be assessing for both suicide risk and suicidality.

Dr. Christina Cwynar:

Speaking a little bit about that assessment piece, there are a variety of different tools out there such as the Columbia, the CASSY the ASQ. What are some of the pros and cons of each of these, and are there target ages for some of these tools when we think about assessing our youth?

Dr. Cheryl King:

The first and most important, I think it is really valuable to screen youth for suicide risk if there is a serious or a significant mental health concern or psychiatric condition, regardless of what the condition is. So, the most important is to screen and then we come secondarily to which tool would I use and what might be the most appropriate tool in this particular setting. I think all three of these tools are valuable, have their uses. There are some pros and cons, so let me just share a bit about each of them. So, let's start with a Columbia, which we think of as the Columbia Suicide Severity Rating Scale or the CSSRS. This tool has many different versions available online free. It has been disseminated in many languages. They've developed a pediatric version. They've developed versions where you're assessing different periods of time in history. These have not all been studied thoroughly, empirically, but they're all quite similar.

And one of the Columbia tools is considered the screening tool. And this one just has six questions so it doesn't take very long to administer. It takes a bit of time because although you could use it as a self-report, and my team has done that in some of our clinical science nationally, it's generally administered as an interview. But the first two questions are about thoughts of death and dying, not waking up, and then thoughts of suicide, suicidal ideation. And the way the screening tool works, if that second one, thoughts of suicide is a yes, then you go on and ask three more questions. Has the youth thought of a method? Do they have the intent to kill themselves? Have they come up with a plan? And then everyone gets the sixth question, which is whether or not they've engaged in any kind of preparatory behavior or action toward making a suicide attempt.

And the screening tool has a recommended triage for low, medium and high risk. And, of course, the higher risk is if there've been any planning. Intent or preparatory behavior. So, this tool, the pediatric version, is the same, although the questions are reworded a bit, just to make it a bit simpler. The one with adolescents and adults has definitely been studied empirically. It does seem to be a valid screening tool that offers some information not perfect. None of these tools are perfect about risk for suicidal behavior. So that's a commonly used tool because it's been so widely disseminated. And in many systems, the preference is for a clinician administered tool in that setting because clinicians are available and they're available to follow up. So that one might commonly be used in healthcare settings or emergency departments. The Ask Suicide-Screening Questions, the ASQ is very brief.

It requires less than 30 seconds to administer. It is a self-report tool. It is a positive screen. If any one of the four is positive, so you can take a very quick scan, see if you have a positive screen. It is put out there for all ages of youth who can read. So, we might be talking about ages, even seven to 10, many people would argue maybe start using it at 10, some people younger. I think that's going to vary with the particular child and what the situation is, how important it is to do the screening. And the four questions again, one is in the last few weeks more about thoughts of death and dying.

"I or my family would be better off if I wasn't here." And then a question about more recent suicidal thoughts and ever in your life made a suicide attempt, engaged in suicidal behavior. And again, there's a triage. If there's any suicidal, any positive, the idea is to do further risk assessment. And if there's any positive, you ask an additional question, "How about right now?" And if the youth is suicidal right now, then of course there's all of the immediate safety precautions. So that's a tool which can be used as self-report, a very quick screen. It's been used in schools, healthcare settings and other settings. Finally, the third one, the CASSY, the computerized adaptive screen for suicidal youth, which we recently developed with funding from our National Institute of Mental Health is different in that it's adaptive. So, whereas the CSSRS, the Columbia and the ASQ are classical screens, everyone gets the same questions and the criteria are set for what means a positive screen.

In an adaptive tool, depending upon the youth's responses to early questions, they get different questions. So, what we did, and this is why we developed this with many pediatric emergency departments nationwide, we needed a really large sample of young people to develop the algorithms to create an adaptive screen. So, it has the advantages of being a bit more tailored to maybe the different indices of suicide risk.

And it has the disadvantages that you have to be set up with an iPad to link to the computer for the adaptive screen. So, there's a setup piece. In terms of how they fare, the ASQ also fare as well as a screen where the CASSY has the advantage when we've studied it empirically is with youth who come in with behavioral health issues. And I think because the ASQ is quite broad, it identifies it, the CASSY gets a little bit more detailed because if the youth reports ideation, it might ask about intent. It might ask a bit more to know the level of risk.

But the bottom line is that all of these screens have their place, they all have some predictive validity in terms of an outcome of suicidal behavior. And whether we want clinician administered, self-report, something that is a bit more specific and sensitive if we're working with behavioral health issues might make a choice. The CASSY was developed specifically as a universal screen for youth coming into emergency departments.

Dr. Cody Weston:

All right, and that's a subject near and dear to my heart since I do spend a lot of time in our psychiatric emergency services. But if I'm hearing you correctly, the most important thing is that clinicians do some form of screening more than agonizing over which tool. Since these all sound like they have considerable value. And it sounds like the CASSY might be an advantageous tool to use across all environments if people have access to the appropriate infrastructure. What barriers do you foresee to people doing these screenings in the clinical setting? Is that something you've encountered frequently, particularly in I guess general pediatrics and primary care settings?

Dr. Cheryl King:

Well, there are many challenges which are barriers to doing screening. And one of the most important things about suicide risk screening with young people is that we don't want to do this screening unless we're prepared to follow up with positive screens. So, there are also challenges with the screening we can talk about. But I think the biggest challenge is are we ready to begin screening and what will be our clinical care pathway for a positive screen? This usually means if we're in primary care or pediatrics, are we in a system that's big enough with enough behavioral health resources in our setting, varies greatly in hospitals across our nation, that we have individuals right say within our setting or department who could come and do a secondary screen and make a determination of whether or not we need a referral to psychiatry or mental health to bring in a mental health expert or professional to do the more comprehensive risk evaluation in formulation.

Or are we in a setting where we don't have those resources and any positive screen will immediately lead to a referral? And then are those people available? We have places where it's on call crisis people coming into the hospital or its people coming from another department, from psychiatry, and are they tied up there? So, because one of the challenges with our screens is that there's still too many false positives, we probably cannot do better than the CASSY. I think that's what most of us in the field are thinking with screening. That's adaptive, it was developed with thousands of youth and youth suicidal thoughts can vary, right? They can vary. We can ask them more than once. They can tell us something a bit different. They can report that the attempt was really not suicidal the next day. It's hard to get a handle on it because sometimes it's based at that time and how much emotionality is and how recent was a disruption or distress.

And there is no time in our human lifespan when the proportion of suicidal thoughts to actual suicidal behavior is so high. So, it makes it a little bit more difficult sometimes in a lot of clinical judgment we have to take it all seriously, but what is the risk for suicidal behavior? So, it's a difficult prediction. We can't predict a suicide, any event that low frequency, but even predicting suicidal behavior in the near future is challenging in young people. So do we have the resources and can we put a system in place so that we have adequate follow up to positive screens and a mechanism for being sure that we share it with a caregiver, go over next steps and get a more comprehensive evaluation if needed. That's the biggest barrier because that takes resources. There are also barriers to screening. There are fewer. Universal screening, I think we found it's quite possible, but we do identify risks. So, we need that next step.

But for instance, even with the ASQ, who will hand it to them, can we sit them in a private space so their parent is not the one filling it out or watching or telling them because we want them to be comfortable filling it out. And then can we be sure someone looks at it before they leave? And that's not insignificant. We can't have them fill out a screen and then they are discharged from the emergency department. And there were so many people involved on the team that no one person saw it as their responsibility to check that screen. And this creates obviously a double concern for the safety of the youth and the risk for the setting for not having followed up. So, there are definitely challenges and most of them are not cost.

We just recently completed a paper that will be published soon, I think it's available online, about the cost of youth suicide risk screening. And when you look at the overall cost, this was in an emergency department, of an emergency department visit. Even when you factor in the cost of getting the mental health follow up and care, it's actually quite a trivial amount relative to the cost of a visit. Yes, with a CASSY, a setting would have to decide to invest in the infrastructure, integrate it into Epic, into the electronic health record and there's a cost to integrating it. Once that's done, the cost is not very much per year, but these costs I don't think are the major challenges. It is the clinical pathway, the infrastructure, the will, and with all of the many priorities we have in healthcare settings for that system to decide to make this a priority.

Now, we do believe that currently without a doubt, we have a crisis in children's mental health in our nation. We have more and more young people reporting, depression, anxiety, stress and sleep problems, preteens, teens. Doesn't matter the survey that we do, it is really increasing. Many people struggling with the transition from being an adolescent to being a young adult. So, I think maybe as a nation we've not previously had as much of a consensus as we do now about the importance of focusing on children's mental health. We've had many of our national organizations come out call it a crisis. We've had the surgeon general come out and label it. So, I think that we will begin to see more screening in healthcare and school settings.

Dr. Christina Cwynar

I think the other big barrier that I've run across, and Dr. Weston, you've probably fielded some calls about this too, is our general care providers, our bedside nurses, just having that paralysis around the screening tool. Like, "Well, how do I ask this questions? Well, what if they say yes? What do I say?" And them just not knowing how to even interact with our youth that are suicidal and being fearful of that correspondence of saying something wrong, making things worse. And we've been working on our consult team of breaking some of that stigma and empowering providers to have those conversations and providing hope and empowering our youth to disclose to them and all of these powerful things. And it starts just with that simple question, but sometimes it's a scary thing to ask, but putting yourself out there and thinking about it as this is for the safety of this child.

Dr. Cheryl King:

Yeah, I'm so glad you've raised this because fear is an important and very real barrier. I think on the one hand, that's one reason that screening tools can be helpful. It's a way to begin. And then we're following up what they checked or said on that tool with more questions. But the fear is not only among healthcare professionals, it can be among mental health care professionals and certainly among caregivers. The fear of, "I don't want to make it worse, I don't know what to say." Our group has developed a youth nominated support team intervention where the youth nominates adults from their world that they trust, that they feel could be helpful to them. And we intervene with those adults to give them the tools and practice and comfort they need to be supportive to the youth. And to learn with the youth and parents' permission, what's going on with the youth and how they can be supportive.

Because often because of stigma, the youth has not shared it. And these adults will say the same thing, "I need help. What do I say? How do I ask it?" And I think for all of us caregivers, healthcare professionals, this isn't something we can do or that we're comfortable doing unless we practice it and we have the words to say. And something like, "I care about your wellbeing. I wonder how you're doing? Given all that's been going on with you at school and what's happened here with your family I wonder if you might have had thoughts of suicide, of death or dying." Finding a way to phrase it where we start with "I care. I want to try to be helpful. I'm wondering," not just like we have a checklist that we're going through. "We have to be sure we ask this and we ask this and we ask this," but more looking at them and validating that we sense they're in pain, that they're distressed and that we do care.

"I see your pain or your distress. I care. I'm wondering," and there are different ways we can learn to say this. Some is "Given everything, da, dah, dah, dah." So, in other words, we're saying "It's okay, we wouldn't stigmatize you. I wouldn't be surprised at all." Or it might be many times I found working with teens that when they're dealing with depression like you are, so we're normalizing it, they share that they've had thoughts of dying, thoughts of suicide. "I wonder if that's true for you sometimes," make it easy to talk about. I think one thing we've learned similar to problems like alcohol misuse and drug misuse, people find it's a bit easier to say they used to have the problem than that I'm having it today. So, we might ask a teen or a young adult about alcohol and drug use. They might say, "I used to have that problem, but I don't anymore."

But when we follow up, the last binge was last Saturday because their intention is to not have the problem anymore. And that truly is their intention. And one of the things we've learned is a risk factor, it's not just current ideation in a youth with other risk indices, it's the fact they've had severe ideation before. Because they may have it again, even if they're not at the moment we ask or they're not comfortable sharing it at the moment we ask. But I'm glad you raised fear because that is something that we all have to some degree and it's most helpful if we share that we have it and we talk with our colleagues about ways to ask and support each other.

Dr. Cody Weston:

Something that comes to mind for me is this idea that the inadequate resources are another significant barrier. And I often worry if we have a positive screen and we're sending somebody through this pipeline, if that means they're waiting in a psychiatric emergency room for 48 hours to be worked up because they have inadequate staff. That's going to deter them from being honest in those screenings in the future. So I wonder if you have any thoughts on that and if there are any ways we can try and shorten those pipelines other than having more hands-on deck?

Dr. Cheryl King:

Yeah, without question we have a shortage of specialized mental health services and there are some real disparities in the availability of these services for youth in different communities and with different means economically. So one of our concerns in the field is the disparities, but across the board, we don't have enough services and what can we do about it? Part of this is public policy certainly, part of it has to do with whether or not we provide funds for mental health care as part of healthcare for all young people. Part of it is also our training pipeline and how we can encourage more people to go into mental health and develop paraprofessionals perhaps who have some of the skills to help with some types of interventions. I think that's one reason we developed the youth nominated support team, not just that families needed support when they went home from the hospital with a youth who had been there for acute suicide risk.

They were waiting for an appointment sometimes for 1, 2, 3 weeks and feeling overwhelmed. But also even if the youth hasn't been in the hospital and they're just screened positive in the school setting, can we have a community where we have enough people understanding what's going on or significant others that a way they have their arms around them as screeners. It's like more gatekeepers for youth mental health. And by that I mean adults who have regular contact with many youth and with training, they could come to understand what are some of the signs or symptoms of suicide risks. What could I say, what am I comfortable saying and how could I get this youth to some kind of services? Maybe it's more support in the school with a teacher being asked, "Just keep an eye out." Maybe we can get this youth nominated support team out where there's more adults meeting with the youth more regularly.

But I do think we need this specialized mental health treatment for these youth too. And I would just agree that we don't have enough of it available at this time, but I think it's better to be waiting than to not have it recognized. So one thing that we're try to be really thoughtful about is the first time a youth shares, I think it takes a lot of bravery to share, to go get help, mental health services. Or to tell someone who asks, "Yes, I have had these thoughts, a thought of dying, a thought of suicide." How we respond to that is likely to impact whether the youth shares it again, is comfortable getting help. And so the idea that someone listens, takes it seriously, "I hear you. You're in pain. I want to take the steps we need to take to get you help," and maybe gets them on a list, but in the meantime is offering support and talking with them. I think that's the best we can do and that's well worth doing.

Dr. Cody Weston:

Yeah, I like your idea of looking at everyone in the community and how they can contribute so that the Swiss cheese has fewer holes in it, so to speak. So a common misconception that we hear is that a person wasn't depressed when they attempted or completed suicide. Can you help explain how someone can be suicidal without being depressed? I know you alluded to that earlier, and I know one of the comorbidities that often comes up is impulsivity related to things like ADHD and perhaps substance use. But I wonder if you could expand upon these other factors contributing to suicidality outside of depression.

Dr. Cheryl King:

Mm-hmm. Right, because suicidal ideation and behavior is one of the signs and symptoms of depression. But a person may experience these without actually having sufficient signs of symptoms to really have a clinical depression or a depressive disorder. On the other hand, clinical thoughts of suicide, suicidal behavior can occur with pretty much any psychiatric condition, probably sometimes with one not even present. So, let's look at a couple of examples. Strong negative emotions that are temporary. So, we may have a suicide. Let's say we have a teenage male who does not manage, cope well when they have strong negative emotions and they may be misusing drugs or alcohol, and then they have a serious argument with a girlfriend or a serious disciplinary action and their phone is taken away and they're restricted to the house for some period of time. Extremely upset, cannot cope with that negative emotion well, and they start drinking, which of course is a depressant.

And what you have is a combination of factors, it's not a whole constellation of depressive symptoms, but it's more time limited, negative emotion. They're under the influence. They become acutely suicidal for a period of time. We have suicides that follow that kind of profile. Another example is severe anxiety, post-traumatic stress disorder. Again, that's a strong distressing negative emotion. There could be sleep disturbance with it, which we do know can increase risk. There can be a disruption of relationships. And it's when we have these multiple risk factors usually occurring together that we get suicide risk.

And this can definitely occur with other types of problems with negative emotion, problems with personal pain and distress, any condition that increases one's hopelessness about their place in the world and how successful they'll be, that increases their difficulty in relationships with others. We do know that damages to connectedness, a sense of belonging, feeling like a burden are all risk factors too. So, it definitely can be present without depression. And that's why when we're working with any young person who's distressed or who struggles with negative emotion or who struggles with alcohol and drug use, that we want to assess for suicide risk.

Dr. Cody Weston:

Okay. Yeah, it's a fascinating dilemma, this idea that we have to consider someone's longitudinal risk as well as their acute risk. And that's something I often struggle with in the emergency department because often by the time someone's presented to the emergency services, the most acute period of risk has already passed. And knowing what to do with that is not always easy since we have to pick apart how likely that is to happen again, based on a lot of the factors that you pointed out.

Dr. Cheryl King:

The understanding risk is challenging because there are so many risk factors for suicide among young people. And it's also important to distinguish warning signs from risk factors. And I think in the emergency department, which you're referring to, we generally are focused on acute risk, acute safety concerns more so than are they going to be at risk in three weeks. It's not unimportant, but our role is what is the acute safety concern? And when we think about warning signs for suicide risk, we're thinking about suicidal communications. They're sharing thoughts, they're writing it in their text messages, they're leaving notes on their desk, they've somehow communicated a suicidal message or the second is hopelessness, expressions of hopelessness. And a third is severe emotional pain, however that appears or shows itself for that young person. And the fourth is changes concerning changes in their behavior.

And what we're learning, we have been studying warning signs, we just finished a very large study of 24-hour warning signs for teen suicide attempts. Two of the ones that parents can notice and do notice are suicidal communications and withdrawal. Withdrawal from usual activities or relationships. And we learned this by asking about what they saw happening with the youth the 24 hours before their attempt versus the 24 hours before that. We call it a case crossover. So, we're looking, what were the changes because all of the youth that we were working with had suicide risk. So, what changed before they actually engaged in an attempt?

So those are really the four warning signs. Suicidal communications, worrisome behavior like sleep disturbance, withdrawal, hopelessness and severe emotional pain. But the risk factors encompass demographic, clinical depressive, bipolar disorder, aggression, substance use, alcohol use, interpersonal factors such as victimization, trauma, sexual abuse, physical abuse, environmental factors like availability of lethal means. So, there's many, many risk factors. I'm only naming a subset and that's why it's a clinical judgment and takes a careful formulation to weigh which of these are present and then which are more acute, and what are the warning signs.

Dr. Christina Cwynar: 

Yeah. And I think it's really important to focus not only on those risk factors, but the warning signs when we're doing those acute assessments. Kind shifting gears a little bit more, but in season one, we talked a little bit about this, but given your expertise, I thought we would pick your brain about this a little bit. But what advice would you give patients and families on lethal means reduction and what should we include in that conversation?

Dr. Cheryl King:

It's an important conversation, and I think the approach to the conversation is key. And this is that the conversation is respectful of their values and perhaps their unique needs and uses of things such as firearms, that it is focused on the youth's safety and harm reduction and that there's no judgment conveyed. This is extremely important. We have been working in different communities, including the upper peninsula on safe firearm storage, and we work with community partners there to learn how can we best approach this? What can we learn from you? Who should be the messenger for safe firearm storage? How should we share it? But a few ideas, and of course, lethal means restriction counseling, really first to both assessing what are the risks, what kinds of lethal means might be available in the home setting. And secondly, how can we talk with the family and take some steps toward harm reduction, the possibility of harm reduction.

And to use firearms as an example, sometimes an information sheet can be helpful as part of the conversation, particularly if it's culturally tailored. But some information like the fact that many parents are not aware of, that most young children do know whether firearms are in the home. Many times parents are surprised by that they didn't think their children knew where the firearms were. That's not what surveys show. From ages five up most children, the majority now, they may not be aware of the number of accidental firearm deaths and injuries in homes. So, there's certain kinds of information that I think could be like a wakeup call, but I think the conversation is more like a decision aid conversation. Can we help you make some decisions about next steps you'll take? The goal with a firearm, of course, is that one, it's removed from the home, at least during the time someone's at risk or two, it's stored, locked and unloaded, and the ammunition is stored, locked in a separate place.

There are some homes where we're not talking about one firearm, we're talking about five or 11 or 12. "We have long arms for hunting. We have handguns for safety. We have the ones passed down in the family. We have this trophy one here, and we have one in the shed and one under the car seat and one here." Well, we're not going to tell that family "Go get them all and take them to the police station." We need to have them understand the importance, the safety, and figure out what are the next steps you can take to make your home a safer place.

Just like we do with when people have their first baby, right, their first child, there's often a high level of motivation, "I'm going to lock up the knobs on the stove and I'm not going to let the toilet seat crash. And like all kind, "I'm putting a plug cover on every plug." It's akin to that. And sometimes we can get families in that mindset, just like you've done things for safety with your children in other ways, this is another kind of safety and there are steps you can take.

Dr. Cody Weston:

Right, yeah. And in having those discussions, I often find it helpful to try and emphasize that it's not about trying to make the access impossible, just to buy the safety system more time to react, whether that's the patient's own sense of protective factors kicking in or someone else being able to intervene. It's impossible to limit access to every possible lethal means in a community environment. So, I often find people respond positively to setting those expectations. I don't know if that's been your experience.

Dr. Cheryl King:

Yeah, I like that. That is a harm reduction approach where if these are locked, unload, and then ammunition is somewhere different, we probably are not going to have an accidental firearm death among small children who find it and are playing with a loaded gun. We do have more time for the person who is very acutely, but only in a moment of high emotionality suicidal. If it's complicated and there's more steps, and we are buying ourself that space. Similarly, something like pills, we can work with families and they're often very willing, "Oh yes, I have some of these sedatives in my drawer or painkillers, and I think I have probably a lot of them." The idea of removing old unused medication, that's one that families will often put on their plan if we do a plan with them. "Well, what are immediate steps you could take?"

"Oh, I could put the ammunition in a different place and lock it. I could find that old medication and throw it out." I feel that's a success. And then maybe they have a mid-range plan. "I'm going to look into gun storage and locks." I can give them a handout. We can have them with me. I have plenty of them. "Well, here's your options and here's what they cost." People want that information. What are the options? What does it cost? Because they may not take the initiative to go figure all that out. So I think if we think of it as what are my first steps and what could I look into after that and can you help me with an idea of what I could do?

Dr. Christina Cwynar: 

Absolutely. So, we've had some really rich discussion today. Are there any more thoughts from anybody around the table before we end our conversation today?

Dr. Cheryl King:

I would just say or emphasize that every single one of us can play some part in suicide prevention. If it's a family or community member, it might be understanding more the signs, the warning signs, or the risk factors so that we can approach a young person with care, validate their pain, and try to get them help. If it's a mental health professional, we can maybe learn the specialized treatments for a young person with suicide risk, begin screening. But whoever we are, I think we can all take some step that can make a difference.

Dr. Christina Cwynar: 

Well, thank you Dr. King for joining us today. And thank you, Dr. Weston for co-hosting with me. It was an honor. Thank you so much to our audience for joining us this week, and we hope that you tune in next week. For those looking to claim CMEs or CEUs you can do that at uofmhealth.org/breakingdownmentalhealth. You're able to do this at any time within the next three years of the initial air date. We hope that you will join us next time.