Conversation with Michelle Lang, Ph.D. of RFMH

I had an interesting conversation a few weeks ago with Michelle Lang, PhD, a colleague with the New York State Research Foundation for Mental Hygiene. RFMH is essentially the research and program evaluation arm of the NYS Office of Mental Health. Dr. Lang has completed a pilot study on the feasibility of routine suicidality screening in community mental health, which she conducted in collaboration with the CSPS here at the University of Rochester.

Dr. Lang and her colleagues learned a great deal from their pilot. As someone developing clinician training in risk assessment, I was especially interested in what they discovered about the range of clinician reactions to the idea of screening for suicide risk:

  • Many clinicians shared the popular myth that asking about suicide might make it more likely.

  • There was more resistance to the screening than the implementation team anticipated.

  • Reactions, both positive and negative toward the program were strong.

There were many other lessons, and I look forward to reading the process papers that will come out of the experience.

Reflections: Many of the experiences Dr. Lang shared point to how difficult and loaded the topic of suicide is for clinicians--even the most experienced ones. As a trainer, this highlights to me the need to find predictable and replicable ways to create a safe learning environments, where clinicians feel understood and where their current practice patterns are honored. This can be hard to do when you are suggesting a change in practice. Dr. Lang and her colleagues made huge efforts to support clinicians, yet still encountered challenges.

Making clinicians feel safe enough in a training that they'll consider changing practice patterns involves the tone and stance, as well as the content of a training. In reviewing training curricula, I've discovered that tone, stance, and conceptual starting points are often not explicitly developed. Contrast this with the way people develop treatment interventions and manuals. For example, in the first chapters of Marsha Linehan's highly successful intervention manual, Linehan lays out an entire dialectical worldview that undergirds her intervention program. That kind of elaboration is rare in developing educational interventions. A recent conversation I had with DeQuincy Lezine, Ph.D. underscored this point for me--he advocated for using "logic models" to examine the assumptions and mechanisms behind any community or training program.

Here are a few ideas about tone, stance, and starting points that I'd like develop further:

  • Drawing on Marsha Linehan's work again, clinician training in suicide assessment requires a balance in the "dialectic" between unconditional acceptance and push for change. Why is this balance so important (and difficult) when it comes to suicide? Perhaps Linehan's concept of "invalidating environments" may apply more than we'd like here, as well. Many of the administrative and legal systems in which we work are invalidating and blaming! Furthermore, one's work vis-à-vis suicide is so personal and fundamental that the suggestion of need for improvement can be hard to take in.

  • Another way of considering the stance and tone needed for effective clinical training in this area from a stages of change (transtheoretical) perspective, i.e. that training needs to have a motivational interviewing stance. The trainer must have an awareness of the ambivalence toward change, and present change tentatively and in a way that draws upon the internal motivation clinicians have to improve their practice in this regard. In my trainings, I've found that one way to do that is to talk about the unspoken dissatisfaction I carried for years about the experience of working with suicidal patients--I share with participants that I always found the experience unrewarding and that I had a vague pre-verbal sense that the way I approached suicide was probably not that helpful to the individuals I worked with. In addition to being genuine, that kind of stance may stoke clinician motivation in a way that the public health arguments do not.

  • In addition to these considerations regarding the pedagogical stance, there are also content emphases that might reduce clinician resistance. As I have noted in almost every post on teaching and training, I feel training in this area should begin with what and how clinicians think and that many efforts in clinician training have the wrong starting point-i.e. they begin with the question: "what do experts say clinicians know about suicide or suicide risk assessment" rather than "what do clinicians want to know." In my experience, clinicians are most hungry for how to document their work and decisions so that they can feel less anxious and can focus on doing what is best for the patient. If that's the case (and this remains an empirical question), then documentation should be a starting point...through which other content (including what experts would say clinicians should know) can be delivered.

Thanks again to Dr. Lang for an informative, stimulating, and enjoyable conversation. She is doing good and interesting work with the State. I look forward to reading the papers that come out of her most recent project, and about the next stages of it development.

Presentation to Board of Wynne Center for Family Research

I presented at the Wynne Center for Family Research (WCFR) board meeting today. I presented about our clinical services and about my work in suicide risk assessment, including how it grew out of experiences with suicidal patients in couples and families. The Center board and the faculty of the WCFR were present.

The Board is unbelievable--a real dream team for family systems fans:

Barbara Fiese, Ph.D., Syracuse University
Nadine Kaslow, Ph.D., Emory University
William Pinsof, Ph.D., Northwestern University
Harry Reis, Ph.D., University of Rochester (Liaison)
Frederick S. Wamboldt, M.D., National Jewish Medical Center
Karen Weihs, M.D., University of Arizona

Given the stature and brilliance of this audience, I was both nervous and eager to get their feedback about our clinical service and about the work that has grown out of it. Here are my notes, and some reflections, from the discussion that followed my presentation:

-- One board member shared an experience she had many years ago working with a prominent family therapist as her supervisor. She recounted the following experience:
She worked with the family of an adolescent who had attempted suicide. She wanted to do a suicide risk assessment as part of her session with the family. Her supervisor, at first, discouraged her because it wasn't "systemic." She persisted and ultimately prevailed by offering to do a suicide assessment for each person present (not just the child) and to invite others present to provide input on the others' assessment! The supervisor allowed this as sufficiently systemic.

Reflection: This is a fascinating story that highlights the tension inherent in melding an activity that has traditionally been part of an individualistic medical model with a family systems view of people, their problems, and their strengths. I think few family therapy supervisors nowadays would advise against suicide risk assessment. Suicide risk assessment is taught (with a range of how much) in every family therapy training program. But I'm not sure if we've developed a lot further in terms of the actual how-to. My impression is that most of the time, there continues to be a one-dimensional linear approach to training suicide assessment that implicitly assumes individual therapy and interviewing.

-- Other thoughts:  One key to resolving the potential tension is to think about suicide as residing in a family system. This view goes beyond thinking about family members a "collateral informants", which is how family involvement is often described in the suicide literature. Instead, we need to develop conceptual AND CLINICAL models for assessing risk through the lens of interactions, relationships, roles, and family myths. For example, how does the hopeless that registers in the individual grow out of family roles and interactions...or from a strength-based approach how might shifts in the family give greater hope to the individual experiencing suicidality.  It is not that this is never talked about, it's just that the focus on individual psychopathology and personality often overshadows this dimension--and perhaps more so than with other behaviors we assess and intervene with because the act of suicide is ultimately unilateral and done when alone.

-- One member asked about me "sharing" what I'm working on. This is an important question to me on several levels:

  1. Blog. This blog is one mechanism I'm using to share thoughts and discoveries.

  2. Planned publications. I am on the cusp of conducting an evaluation of my risk assessment workshop and plan to publish the results. I am also working on another publication in which I'm collaborating with two faculty members of the Deaf-Wellness Center.

  3. Career Direction. If what I'm doing turns out to be helpful to clinicians and to families, I want to share it widely. That brings up interesting questions about how I spend my time professionally. Given the range of my interests (in terms of content (peds primary care, suicide) and professional activities (teaching, writing, clinical work), it is hard to know the right direction. A career in research is appealing in ways it hasn't been in the past. This is probably a dilemma many of my readers (especially those in academia) are familiar with. I'll be focusing on discerning this over the next year or so.

-- After I talked about this blog, a board member recommended using it as a way of helping to disseminate science to general audience. I have done this a little (such as here), but could probably do more.

-- A board member suggested that, in light of how heavy it is to focus on suicide (an adverse outcome), it would be advisable for our clinical service to also gather stories and data about positive outcomes of family therapy. This is a perceptive and appreciated comment because prevention of a bad outcome does have a peculiar emotional tone for an individual or group. I named this blog "Commitment to living" in part to cast this work in a positive direction. This comment is a good reminder to do that kind of thing in many ways also at a system level.

All of that in 30 minutes! I appreciated the opportunity to consult with such bright and experienced senior experts in our field.

Reminder from the headlines: Suicide not just about depression

The Washington Post reported yesterday that the Virginia Tech shooter had an anxiety disorder as a child.   I don't want to say much more about that, and I don't know enough about Seung Hui Cho to know whether this did or did not play a role in his actions in April.

But such news can provide a useful reminder to review the prototypes and heuristics clinicians have in our heads about suicide.  Specifically, we need to resist the temptation to only think or ask about suicide in cases of depression.  Although depression is present in a large proportion of  people who die by suicide, suicide is by no means synonymous with depression.   Anxiety disorders, personality disorders, and psychotic disorders are all associated with risk for suicide.  This begins to make sense when you think about suicide often being a response to hopelessness, despair, agitation, and a feeling of being trapped (often with an overlay of substance abuse disinhibiting the person's symptoms and behavior).   When put that way, it's not hard to see how chronic intense anxiety could lead to suicidal thinking (or action).

I think this is something many clinicians know, but old prototypes can be stubborn and often get in the way of us accessing what we know.   When we refresh our thinking, we  can more effectively remember to to ask about suicidal ideation in every case, not just when depression is prominent.

Related posts:
Murder-Suicide, Domestic Violence…Common threads in violence against self and others

Suicide turned outward: Times of London Article by Dewey Cornell

Erratum on previous post: Cornell not author, just interviewed

Thoughts about SAD PERSONS Screen

I've gotten a few questions from colleagues and trainees lately about using the SADPERSONS screen. Most recently, a colleague pointed me to an article in Psychiatric Times titled, "APA: Simple Screen Improves Suicide Risk Assessment." The topic seems worthy of a post to think through both the appeal and risks of the SADPERSONS scale.

For those who are not aware of SAD PERSONS, it is a 10-item scale to purports to screen for suicide risk. An individual is given one point for each item for which he or she screens positive:

  • Sex (male)

  • Age less than 19 or greater than 45 years

  • Depression (patient admits to depression or decreased concentration, sleep, appetite and/or libido

  • Previous suicide attempt or psychiatric care

  • Excessive alcohol or drug use

  • Rational thinking loss: psychosis, organic brain syndrome

  • Separated, divorced, or widowed

  • Organized plan or serious attempt

  • No social support

  • Sickness, chronic disease

The word "simple" in headline of this Psychiatric Times article linked above captures what makes the tool sound appealing, especially for the thousands of health care systems that need a quick way to respond to the JCAHO patient safety goal 15 and 15A: "The organization identifies safety risk inherent in its client populations" and "The organization identifies clients at risk for suicide" (see this .pdf for explication of these goals).

From one perspective, there is nothing wrong with using acronym like this. It can remind clinicians (assuming they can remember what all the letters stand for!) of some of the risk factors and warning signs of suicide. Who can argue with that? However, from a training and clinical perspective, there are a few problems with this approach, especially when the screen is put forward as a scored scale. Let me summarize a few of these. Note that my thinking about some of these concerns is strongly influenced by concerns articulated by my senior (and very brilliant) colleagues in email exchanges we have had about this. I don't claim originality here, just summary:

  1. The "scale" assigns risk level on the basis of a point system: A score of 1 or 2 points indicates low risk, 3-5 points indicates moderate risk, and 7-10 indicates high risk. This approach works under the assumption that these factors are equally weighted. A separated, 46-year old male with diabetes with no depression would have a higher risk level (score=4, moderate), than 40 year-old married woman with chronic depression, current hopelessness who was just released from a psychiatric hospital after a near-hanging. (score=2, low risk).

  2. Having a risk "score" creates conditions for clinicians to rely on a number instead of developing an informed clinical formulation of risk.

  3. The suggestion that risk for suicide can be boiled down to a single number--even for screening purposes--presents a misleading picture of the complexity phenomenon and how to think about it as a clinician.

  4. The evidence that the linked article gathered does not correspond with the alluring headline, "Simple Screen Improves Suicide Risk Assessment." Evidence reported by those who conducted the study was that, after using the computerized screen, nurses tested showed more knowledge about risk factors for suicide. Of course, knowledge about factors is a long way from demonstrating improved assessment. Obviously, the physicians who reported their study at APA the study did not write the headline. The semantic overreach of the headline speaks to the understandable desire to find easy ways of doing hard things.

  5. Finally, from a training perspective, I find acronyms longer that 3 letters almost impossible to remember! SAD PERSONS particularly clumsy, and, IMHO a bit forced. "O" stands for "Organized plan or serious attempt" whereas I would probably make plan a "P" if I were trying to remember it, but of course that's already taken by "P" for "Previous." That often ends up being the problem with trying to make these things fit into an acronym. In a way, this gets back to the theme I've been harping on lately in my posts about teaching and training about needing a basic-science base about how clinicians learn, remember, and use principles or practices we learn. I'd imagine an expert in human memory could graph the inverse relationship between recall rate and number of letters in an acronym--add to that the need to recall these letters that signify words or concepts with high emotional impact.

In summary, while SAD PERSONS may be helpful to some people as a tool for remembering risk factors, it has some serious limitations as risk assessment "scale" and probably as a mnemonic.

Possible implications of findings re: visual memory

Readers of this blog know that I am interested in mindmapping and other visual presentation strategies as tools for training clinicians in suicide risk assessment (see related posts listed below).  In a previous post marked "needs development" I noted:
Really, there is a “basic science” set of questions about learning and the clinician mind that gets skipped over when we do the necessary and important work of evaluating educational interventions.

Thanks to a post on PsychNews, I came across this interesting article in Cognitive Daily that attempts to provide some explanations for why visual memories are often so vivid.  One of the take-home points of the study cited in the article is that the vividness of visual memory is directly related to the duration of viewing.    This is unsurprising in some ways, but it supports the educational strategy of using one or two maps or other graphics (rather than a multitude of Powerpoint slides or text handouts) to teach about a clinical concept like risk assessment.   Participants in my trainings, for example, view one map (whose branches I dynamically hid and show) for nearly the entire presentation.

These little bits of basic science evidence remind me, once again, that we pay too little attention to the evidence base of our teaching techniques.   It is well and good to decideto pursue evidence-based interventions and therapuetics (EBIT, as we call it around here), but what is often missing (besides a coherent notion of what constitutes evidence--a topic for another day) is an evidence-based way of disseminating evidence-based practice to clinicians.

Related Posts:

Visual maps and guides in high stress situations

Mindmapping coping strategies

Evidence for visually different presentation format

Tech tools for clinical thinking and training

Owner of Chinese Toy Factory Dies - New York Times

Almost nothing is known about this factory owner, so we should be careful about what lessons we draw.  But this news is a sad and startling reminder that job loss and financial pressure (here mixed with public humiliation) raises risk of suicide.
Owner of Chinese Toy Factory Commits Suicide - New York Times.

Conversation with Paul Quinnett, Founder/CEO of QPR

I talked yesterday with Paul Quinnett, Ph.D. Founder and CEO of the QPR Institute. He has been working in the field of suicide prevention for decades and has developed an excellent set of tools for clinicians. I enjoyed the conversation because Dr. Quinnett is bright, experienced, and passionate about his work, and also because of the conceptual overlaps I observed through our conversation. Here are a few from my notes:

Technology Transfer. Dr. Quinnett’s interest is technology transfer, i.e. taking what is known from the literature and clinical experience giving it legs for the working clinician and healthcare system. This the primary thrust of my evolving work, as well. I also have an interest finding the most efficient and effective pedagogical method for transferring information.  This is where my interest in mapping and other forms of visual representations comes in (see my previous mapping posts). This topic is also part of what has interested me when I heard Wendi Cross speak (see my post reflecting on Organizational factors that support care of suicidal person).

Family involvement. I’ve posted several times (see Where’s the Family?, and At the crossroads of family therapy and suicide prevention) about the conundrum that family involvement presents for suicide risk assessment: we don’t have good models for talking about suicide with family members present, we don’t have clear ideas about how to incorporate families in the assessment process, AND in many cases it is impossible to imagine performing a worthwhile assessment and management plan without family input.  Dr. Quinnett has been working on this very issue from two interesting perspectives. The first is what he called “the cost of data collection.” That is, he is curious about how clinicians perceive the cost of collecting information from 3rd parties. The second is that he is working on developing a protocol of the key questions and info one should ask/gather from family members to guide clinicians in their interviews. Dr. Quinnett has been working on this with Sergio Perez Barrero, MD, a psychiatrist in Cuba who founded the Suicidology Section of World Psychiatry Association and also the World Suicidology Net.Dr. Perez Barrero is a QPR trainer, who has translated the materials in to Spanish.

Drawing on experience in other fields that do risk assessment.  In a previous post, (Reflecting on Intersections with Knowledge Management, Dave Snowden, and Singapore’s Risk Assessment and Horizon Scanning System), I shared my reactions to Dave Snowden’s work on detecting terrorist threats. Dr. Quinnett was struck in a similar way by Gavin deBecker’s work in threat assessment. I had not heard of deBecker but apparently his California firm, Gavin deBecker and Associates works with high-profile clients (including Hollywood celebrities) to analyzing potential threats to their safety. He has written a book called “The Gift of Fear,” which I plan to read on Dr. Quinnett’s recommendation.

Along similar lines, I have consulted with a forensic psychologist and friend, Daniel Murrie, Ph.D., who co-authored a book (with Mary Alice Conroy) coming out this fall about assessment of risk for violence, “Forensic Assessment of Violence Risk: A Guide for Risk Assessment and Risk Management.” This book, which I’ve seen excerpts of, presents an approach to assessment of risk for violence that is clear and accessible to clinicians and retains the richness and clinical complexity that appropriate to the challenging work of predicting an individual’s risk of being violent. The approach that Conroy and Murrie take has potential applicability for suicide risk assessment, for which we’ve never quite had such a clear model for conducting and writing assessments.

I guess the intersection here relates to seeing potential for developments in threat and violence prediction work to help our efforts to improve detection of suicide risk.

Desire to understand the clinician’s state of mind when faced with risk assessment. I have noted before (see my post on Visual maps and guides in high stress situations) that I’m interested in learning what the cognitive science would be related to how people best access information for decision making in high arousal situations. Similarly, Dr. Quinnett mentioned that he would like to test clinician perceptions about information gathering in risk assessment. What kind of cost/benefit appraisals do they make about asking questions and gathering collateral info?

In my view, the clinician’s state of mind/emotion and cognitive heuristics are underappreciated in most approaches to training about suicide risk. As I noted in my post about clinician anxiety (Clinician anxiety–what’s it about?), what we believe about the most pressing concerns for clinicians will influence what and how we teach. Likewise, understanding how clinicians learn best is important for modes of dissemination (for example, see my post on How clinicians learn: Web 2.0 Opportunities?).

Summary: “Needs Development.” This is another post I’ll tag “needs development” because much of this raises more questions than it answers.   But reflecting on these conceptual intersections helps me to see how much is not known about how to approach training in suicide risk assessment.   Really, there is a “basic science” set of questions about learning and the clinician mind that gets skipped over when we do the necessary and important work of evaluating educational interventions (which, of course, we don’t do enough of either!).

Risk of suicide in young children

There is a lot of material available about assessing for risk of suicide in adolescents, but much less that focuses on small children. Some cases are relatively (and I mean relatively) straightforward, like the child who says he is going to kill himself in anger when he doesn't get his way. But I have seen a fair number of young children where it is more complicated. Some of them may express the suicidality in anger, but they also take actions like grabbing a kitchen knife or putting shoelace around their necks and pulling it.

Now, in all of the cases I have seen this action has been taken in full view of parents or other adults, which makes it somewhat less concerning (at least in terms of immediate risk for suicide), but nevertheless the child has taken an action which, if done at another time and in a slightly different way could be dangerous.

Our frameworks for assessing risk in adults fall short in these cases. I know I feel on less steady ground. If anyone knows of good resources--ones that not only provide risk factors, but ways of conceptualizing suicidal behavior in young children, I'd love to hear from you.

Genetic Variations May Predispose Some Men To Suicidal Thoughts During Treatment For Depression

Genetic Variations May Predispose Some Men To Suicidal Thoughts During Treatment For Depression

Researchers at Harvard/Mass General have contributed some interesting data to the conversation about suicidality and antidepressant treatment. Roy Perlis and colleagues examined available DNA info on patients who had new onset suicidal thoughts after starting drug therapy, and found an interaction effect (sex x genetic variation) that suggested that the men with the genetic variation were at greater risk of suicidal thoughts. The article by Roy Perlis and colleagues appeared in the most recent issue of Archives of General Psychiatry. For a lay description of the study see this article in Medical News Today.

Because of the nature of the sample and the narrow scope of the findings, this study contributes most to the understanding about a possible link between suicidality and antidepressant use, about which I have posted before. But my main interest in it here relates to what new findings (especially those with a strong biomedical basis) mean to clinicians and how we think about risk assessment.

If replicated and expanded findings like these might lead to more targeted approaches to suicidality (and probably psychopharmacology for depression). However, for the clinician faced with an at-risk person in treatment, each new discovery will be merely one factor to synthesize into an overall, well-constructed risk formulation. It is doubtful we'll ever get to the point where a single data point (genetic or otherwise) will be strong enough to predict risk by itself. We'll always need good, old fashioned, clear-headed, complexity-embracing clinical judgment to discern risk. In fact, new findings related to risk (especially complex ones like those in the Perlis study) point out the importance of having a sturdy framework for thinking through risk assessment. A systematic framework allows the clinician to incorporate new findings into thinking and practice.

The need for a framework for thinking through risk may seem too obvious to mention. But consider what most training in suicide risk assessment consists of. Nearly every clinician I've spoken to (including myself) learned to assess suicide by asking a few basic questions about suicidal thinking, plan, intent, and ability to agree to stay safe. Most of us were not taught a "framework at all." We did not learn to assess for suicide risk the way we do other clinical issues--via systematic assessment and synthesis of multiple data points. In my opinion, that is why many clinicians I talk to feel so unsatisfied with the experience of working with people who voice suicidality.

All that to say...we're likely to see more genetic links with suicide risk. My goal is to be prepared to assimilate new findings within:

  • a compassionate and autonomy-respecting approach to gathering data (of all kinds) and intervening

  • a systematic way of thinking through multiple risk factors to arrive at a formulation

  • a coherent and predictable format for documenting and responding to risk

Murder-Suicide, Domestic Violence...Common threads in violence against self and others

The murder-suicide that took place at Virginia Tech on Monday on a lot of people's minds right now.  Certainly on mine.  So sad.

This event was mentioned several times at a conference I attended parts of today on "Multidisciplinary perspectives on partner violence".   In fact, one of the key speakers, Sandra M. Stith, Ph.D., is a faculty person at Virginia Tech.  She gave a marvelous talk about work she and her colleagues are doing with high conflict couples in multicouple groups.   Before speaking, she made poignant comments about her decision to speak at the conference instead of heading home.   It was clear from listening to her speak that she deeply understood the close connection between prevention of different forms of violence.

Which bring us straight to the topic of suicide.   Catherine Cerulli, a faculty member in our department and one of the conference organizers, gave a powerful presentation titled, "Domestic Violence as a risk factor for suicide and murder-suicide."   As I listened to this talk and to others today, the connection between violence and suicide was unmistakable.  The take home message for assessment is this:  we need to think about violence when we hear suicide, and suicide when we hear about violence.  History of trauma or DV are not just statistical risk factors.   They are intertwined and interrelated in substantive and clinically meaningful ways.  Cate played a horrific tape of a 911 call that illustrated this in a visceral way.  A woman with a past history of suicide attempts, ends up involved in the death of her violent male partner--which occurs during the 911 call.  (It is not clear if she actively stabbed him or just held the knife and he impaled himself).   The relationship between different kinds of risk (violence against partner and violence against self) is so complicated as to be practically indistinguishable.

So...a few free associated questions related to clinical assessment:

When we see a depressed youth with suicidal risk, are we asking enough about violence in the home (past or present, witnessed or experienced)?
When we see DV, how thorough are we about suicide assessment?
When we see suicidal individuals (especially men) who have some antisocial features are we thinking about their potential for violence against others, including (especially) against intimate others?
Are we remembering that involvement with the criminal justice system puts people at greater risk for suicide?

Murder-suicide like the one the country has experienced this week is not a statistical coincidence--it teaches us something about the heart and processes behind both.

Example of risk map

In a comment on my previous post about visual presentation for clinical training in risk assessment, Avi of GUI Yourself requested an example. Here is a .pdf of a map I use. The details are collapsed, but you can get the idea.  I also teach using a map of the options available to clinicians in our system.  I am working to customize that map for each service area I train (with the aim of influencing implementation and transfer, as discussed in this post).

Unintended consequences of antidepressant black box warning?

An article by Charles Nemeroff and colleagues in the Archives of General Psychiatry this month reports reports on the "Impact of Publicity Concerning Pediatric Suicidality Data on Physician Practice Patterns in the United States." (If you don't have access to the journal, you can read a report on the article here.)   The authors show that antidepressant prescription rates for children and adolescents have declined and there has been a shift in proscriber patterns from "generalists" (PCPs) to "specialists" (generally psychiatrists) since the FDA placed a black box warning related to suicide risk.  The warning includes the following statement: "Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders."  You can read the entire warning in a .pdf here).

The study does not study who is not getting medication that might have in the past--just that fewer kids are getting the medicine.  Whether that is ultimately good or bad remains to be seen.

Kelly Posner, who headed the FDA/Columbia Reclassification study, spoke at our Department Grand Rounds last month and lead a seminar with a smaller group of us about the reclassification scheme.  (The reclassification project looked in detail at reported adverse events that started this controversy.)   She clearly thought the consequences of the warning would be mostly negative.   She shared her concern (which has been stated by others as well) that the unintended consequence of the black box warning will be fewer youth treated for depression and more deaths by suicide, as a result.  From what I have read, that remains an empirical question and one that will require careful interpretation of data before inferring causality. What is clear is that the black box warning was probably based more on political and emotional concerns than on science (see also Marshall, Posner, and Greenhill, 2006), and that the risk of untreated depression is probably greater than the risk of adverse events from treatment.

[mounting soapbox]  That said...when this discussion comes up I think it is important to add psychotherapy and counseling to the landscape.  Untreated depression can be deadly, but that doesn't mean the treatment has to be medication.  [coming down off soapbox]

What are the implications for risk assessment?   I'm still trying to understand that.  How I am guiding our clinicians at this point is this:   When conducting a risk assessment of an adolescent or young adult in the first weeks following initiation of antidepressants, we need to note that antidepressants have been recently started.  But rather than name this as a "risk factor" we would do better to note how the medication response will be monitored and indicate the risk-related symptoms that are being targeted by the medication.  That is, connect the medication to the risk factors it is designed to reduce, more than to the risk it might carry.


  1. Marshall, R. D., Posner, K., & Greenhill, L. (2006). Risk Perception Research and the Black Box Warning for SSRIs in Children. Journal of the American Academy of Child & Adolescent Psychiatry, 45(7), 765.

  2.  Nemeroff, C.B. et al. (2007. Impact of Publicity Concerning Pediatric Suicidality Data on Physician Practice Patterns in the United States.  Archives of General Psychiatry, 64:466-472.

Reflecting on Intersections with Knowledge Management, Dave Snowden, and Singapore’s Risk Assessment and Horizon Scanning System

Warning: This post starts out a bit far afield from clinical work. My ideas about how it ultimately connect back, but they're still forming, so this is definitely a "put on your seatbelt" kind of post.

For some time, I have been following the work and blog of Dave Snowden, founder of Cognitive Edge. Snowden is an scientist, theorist, and organizational consultant at the cutting edge of the Knowledge Management (KM) field. Or perhaps it would be more accurate to say that Snowden is a pioneer and visionary who is try to push KM to an entirely different dimension (call it KM 2.0). I must admit that I am still trying to get a handle on Snowden's thinking (it's broader and more complex than I can yet grasp), but one of the most interesting things to me about his work is that he emphasizes narrative (versus purely numerical) approach to "sensemaking." Snowden and others of his ilk argue that you can learn more useful information, detect more weak signals, capture trends earlier through gathering stories than you can by gathering numbers. Stories show emerging trends. Numbers tell you what has already happened.   (For a popular version of this argument see Lori Silverman's provocatively titled book "Wake me up when the data are over: How Organizations Use Stories to Drive Results")

Snowden and another KM guru, Gary Klein, were recently videotaped discussing the methodology (and software) that the Government of Singapore has developed to help them detect terrorist risk, the Risk Assessment and Horizon Scanning (RAHS) system. I found their videotaped discussion fascinating, especially Snowden's critique on the failures of knowledge management (2nd clip on the page). I don't know enough to understand the differences between the perspectives Klein and Snowden offer (and, can't in fact follow all of what either one says), but I listened with great interest to their perspective on how one approaches information-gathering, sensemaking, and decision-making in an uncertain, unpredictable, and unstable environment.

Obviously, clinical sensemaking and decision-making is quite different from government counter-terrorism operations. But I could not help but think of parallels, especially for assessment of suicide risk. Here are a couple of developing (and somewhat random) reflections I had:

  1. We know about statistical risk factors, but how do we do sensemaking with a particular person's set of stories. Clinicians have access to rich narratives, but we generally lack methodologies and technologies for sensemaking that retains complexity and guides decision making.

  2. Traditional documentation (the principal knowledge management system for clinical care), including the diagnostic evaluation reports, usually flatten the richness of stories (by design) into a language that is more technical, linear, and sterile than real life. We usually don't capture stories on their own or track raw data, but rather we move quickly to interpretation and synthesis.

  3. I noted in a previous post that I use mindmapping to teach about suicide risk. In that post, I suggested one benefit might be "it helps to be able to visualize connections between concepts on a map because it makes complex material more accessible." In light of what I'm learning from Snowden and KM, I wonder if mindmapping also facilitates sensemaking from narratives better because it is nonlinear and attempts to replicate connections in human thought patterns.

  4. Apropos of my previous post, Where's the family? therapy offers an opportunity for gathering anecdotes from multiple perspectives. Snowden has a KM exercise called "Anecdote Circles," which he uses to help organizations gather information through story. The techniques he uses would be interesting to apply to a family, and to gathering information from family members about suicide risk. This kind of raw data is not available without family members.

  5. Our models and language around risk assessment needs to better reflect how fluid and unstable the phenomena of risk and suicidality really are. The act of suicide is a momentary coalescing of a multitude of snippets and anecdotes and narratives. Reading retrospective case studies of people who died by suicide makes that really clear--all of what we categorize as "risk" comes together in a certain way at a certain point in time. As one of my mentors pointed out to me last week, we can "predict" suicide retrospectively, but it is almost impossible to detect prospectively.  As clinicians we want to be sensitive to the snippets, so that we can scan the horizon (a la RAHS) and sense emerging trends, far before the data ever catches up.

As I warned in the beginning, these thoughts are pretty raw, but I'm interested in exploring this intersection more.

Where's the Family?

I was just looking at the post counts on my categories and seeing few posts I have (only 2) family therapy category.   I think that reflects the state of the field right now, as well as my own internal conceptual development which is not yet entirely integrated.  Two things for sure:

1.  Almost everything I've read in the clinical suicide assessment literature assumes a one-on-one context.   Family therapy is usually not mentioned.  Families are sometimes mentioned, usually as potential sources of information when things get really risky, but without much attention to how to do that.

2. Family therapists tend to get pretty individualistic when they teach or write about suicide prevention.   This tendency was unmistakable in a recent Family Therapy Magazine, a publication of AAMFT that is distributed free to all members.   The July/Aug 2006 issues was titled "Suicide in the Family."   Yet if you look at the articles there is almost no content related to family therapy.  In fact, if you removed the cover and took out a couple of intro paragraphs, the articles would be indistinguishable as a family therapy publication.   Remarkable.

I think this state of affairs reflects that fact that it's not easy to bring the two together in practice.   How, when and of whom do you ask about suicidality in a room full of family members of different ages?  How do you bring up a topic that is hard enough to bring up with one person in front of you?   How much history about self-harm do you gather in front of children?  I don't think anyone has really spelled out how to translate the relatively linear risk assessment principles to skillful systems work. If there is work in this area, I'd be interested to learn more about it.That said, I think it's hard and we don't have good models, but it is not impossible.  I see our trainees doing it exceptionally well.   It is demanding, but do it well because they are talented and devoted--and because we emphasize it, in part, because of my developing expertise in the area.  But I don't think any of us yet has a clearly-enough articulated model to present as the standard of care.

I feel obligated to add here, that there are some equally hard questions that a family therapist could ask an individual therapist too. can you possibly get a complete risk assessment picture without talking with family members, seeing the patient interact with them, understanding the family pathology and strengths?  How do you monitor warning signs without inside players?   I've lately been reading extensive case reports of people who died by suicide.  In each of the cases I read, it would have been impossible to understand the risk picture without extensive information from family members.  Many of those truly at risk of killing themselves just do not disclose enough and the right kind of information.

This is an area in much need of development.