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TALES FROM THE CLINIC: THE ART OF PSYCHIATRY

Tales From the Clinic: The Art of Psychiatry

, we delve into the world of psychosis and the accompanying suffering from a psychodynamic and suicide risk perspective. Chronic psychotic disorders, exemplified by schizophrenia, bring about terrible suffering and are not fully treatable. Despite advances in psychiatry, we have limited treatment options to offer that can lead to true recovery. Shattered lives ensue, with all the sadness attached. The clinicians who treat this challenging population deserve all our gratitude and support.

“Mr Thomas” was a young male in his late 20s when he first presented at our community clinic to establish care. He was accompanied by his father during the first visit and in all subsequent follow-up appointments. Mr Thomas was visibly shy and anxious during the first appointment. He sat quite close to his father, mostly avoided any eye contact with his psychiatrist, and often deferred to his father for most of the answers. He later revealed the reason for the lack of eye contact was his effort to block the intrusive “inappropriate sexual thoughts” when seeing someone; looking at the psychiatrist would make him think and imagine his naked body. Despite the palpable shyness and anxiety present in the first visit, Mr Thomas gave the impression that he was familiar with outpatient psychiatric care since he had been seeing psychiatrists for years, first for anxiety when he turned 20, and later for bizarre thoughts.

Soon after the fall semester of his junior year, he started having delusional thoughts that he was responsible for the firing of a few employees at a local newspaper because of his hacking into their website and him providing rude feedback on their job performance. In addition, Mr Thomas’ self-esteem and sense of belonging took a major hit because he frequently believed he was causing trouble to others. During one visit, Mr Thomas said he had not slept well the night before because he believed that his neighbor’s dog was barking at him all night to tell him how bad he was and that he would get into trouble. Mr Thomas also talked about his ruminating fear that he would become a pedophile one day due to his intrusive sexual thoughts about children—and, even worse, that his “bad” thoughts could infect others.

The psychotic episodes quickly turned into a distressing experience and sank him further into disorganized thoughts and behaviors. Late in the spring semester of his junior year, Mr Thomas was hospitalized for disorganized behaviors, poor self-care, and suicidal thoughts. Subsequent psychotic episodes and hospitalizations rendered him a harsh reality of a long and seemingly unending struggle with severe schizophrenia.

Nonetheless, despite going through a few more psychotic episodes in the following years, he was able to complete his college degree. In contrast to the sullen look he had when talking about the mental health illness that derailed his life, Mr Thomas spent time during a few visits recalling his childhood and his early years of college with a lot of fondness. Also, behind the flat affect, the self-doubt, and the suffering, Mr Thomas was a deeply caring individual; he regularly donated a significant part of his monthly Social Security check to a local food bank. In one visit, he expressed extreme relief after learning his intrusive thoughts were not contagious and that he was not responsible for others having obsessive compulsive disorder because of his presence. However, when it came to his emotional suffering and daily life struggle, Mr Thomas rarely spontaneously spoke or elaborated when asked.

It has been 5 years since Mr Thomas moved back home after college to live with his father, who has always been a loving and caring figure, but life was not any easier for Mr Thomas. Initially, he was able to find a few labor jobs, but he struggled to hold them: “I do not want to be working around people.” Mr Thomas said he used to be a social person in college, but now he no longer had any meaningful relationships outside of his immediate family. He had not been in touch with his old friends in recent years. The interplay of cognitive, behavioral, and emotional dysfunctions of schizophrenia has led to a long-term impairment of his social and occupational functioning, sinking Mr Thomas into further loneliness, isolation, and a lack of a sense of belonging.

Mr Thomas had been on multiple atypical antipsychotic trials in his earlier years of treatment for psychosis, but the treatment did not make a meaningful impact on his positive symptoms. At the time of his first visit to our clinic, he was already on clozapine; this medication seemed to help with his delusional thoughts of him causing harm to others. However, he still occasionally developed the fear of ruining others’ minds because he believed that they could hear his “bad” thoughts. Also, the intrusive thoughts and images of seeing others in sexual ways continued to torment him, causing a lot of shame and guilt.

Besides taking sertraline for depression, he also had weekly psychotherapy, mostly focusing on cognitive behavioral therapy for psychosis and intrusive thoughts. He found the intervention beneficial, at least partially. At one point, Mr Thomas was able to go to the park and challenge his fear of making eye contact with people by greeting them; however, the intrusive thoughts and imagining others naked never seemed to go away.

Prior to taking sertraline, he was also on fluvoxamine, but it did not have any impact on the intrusive thoughts, even at the highest dose. When the intrusive thoughts became unbearable, Mr Thomas said he sometimes chose to sleep most of the day, so he did not have any awareness of his thoughts and feelings. Mr Thomas’ fears could be more consistent with anxieties higher on the developmental hierarchy. Even though the experience of emerging psychosis during his college years seemed to be devastating, as it burdened the ego with primitive anxieties and deteriorating, his suffering from the psychosis seemed to be much worse in its later stage due to the loss of old self and the confusion of a new one.

Throughout the clinic visits, a sense of loss and grief over the old self was palpable. At one point, Mr Thomas mentioned with a profound sadness that he used to have many hobbies as a teenager. In one visit, he also proudly talked about being selected for his college swim team. These days, he still occasionally went out and swam at a local YMCA, but only when the intrusive thoughts were not troubling him. Otherwise, he spent his time at home checking emails or going to a local library when he did not feel like he was causing problems to others.

Anxiety, guilt, and shame could be unbearable for Mr Thomas at times because of the ruminating thoughts. To him, the thoughts were totally inappropriate; they seemed as if they were part of him, not his illness, especially when he talked about seeing the flash of someone’s genitalia when making eye contact with them. To cope with it, he avoided leaving his house altogether. The only time of the day when he found peace was late at night, walking his family’s dog when there was no one around him.

He never considered using substances to cope with the mental suffering. Mr Thomas belonged to the minority of patients with schizophrenia who never used, misused, or abused any substance, including tobacco, to self-soothe. Research has shown that a history of substance use disorder is associated with a 1.5- to 2-fold increase in suicide rates among patients and can lead to a decrease in executive functioning abilities and a subsequent increase in impulsivity during the course of the disease.

Over the years, the missing sense of belonging and the confusion between his thoughts and reality made him feel increasingly hopeless and helpless. How could he find the future worth looking forward to when he lost his old self? As his psychotic process progressed, more primitive anxieties developed, such as disintegration anxiety and annihilation anxiety. Mr Thomas began to experience the self as formless and diffuse, and thoughts and perceptions became difficult to differentiate.

The container by which patients suffering from severe schizophrenia relate to the outer world has lost its structure. For Mr Thomas, the experience was now not so much of annihilation anxiety, but about himself slipping away and disintegrating. The terror itself can become a companion, providing reassurance that something of the self remains.

Mr Thomas frequently felt indifferent about death because he thought his existence was a burden to himself and everyone else. Mr Thomas drifted further into hopelessness, helplessness, and isolation, despite the love and care from his family, because of the loss of control, the confusion, and the lack of a sense of belonging.

Now, as a young man in his late 20s, Mr Thomas continued the long struggle in his day-to-day existence. The highest risk of completed suicide is recorded among individuals with onset of illness between the ages of 22 and 24 years.

Coupled with the guilt and shame that was exacerbated by his delusional thoughts, the anguish and torment from his suffering became unbearable on multiple occasions. Mr Thomas had been hospitalized 5 times in the 5 years since establishing care at our clinic. Three of these hospitalizations were for having suicidal thoughts, and the other 2 were for serious suicide attempts: one by overdosing on his psychiatric medication, and the other by drowning himself in a swimming pool.

Patients experiencing psychotic symptoms are more likely to exhibit feelings of shame, stigma, guilt, and rejection. Independently, these feelings lead to exacerbation of one’s symptoms, increased social withdrawing, reluctance to seek help, and subsequently a greater risk of completed suicide attempts. Previous suicide attempts are generally considered the number-1 risk factor for subsequent death from suicide. Among patients with schizophrenia, a history of previous attempts early in the treatment period or in the pretreatment period necessitates immediate intervention.

Mr Thomas’ suffering from shame and guilt never seemed to end because of ongoing intrusive sexual thoughts. During one psychotic episode, Mr Thomas felt horrible about himself for having a sexual thought that was transmitted to his right-side neighbor through the vents in his bathroom. The psychotherapy intervention on his delusions and intrusive thoughts was not as effective due to Mr Thomas’ concrete thought process and increasingly poor insight. The effect of insight alone can be paradoxical, as it contributes to the illness’ severity through the mediating effects of depression and hopelessness.

 Living with a diagnosis can make it hard for him to separate his identity from it, leading to feelings of hopelessness, loss of autonomy, negative views of oneself, and demoralization. These factors, combined with maladaptive coping mechanisms and lack of social support, can lead to depressive feelings and internalized stigma at a later stage of the disease.

Although a hospital stay can have positive effects on one’s illness, by ensuring adequate management, symptomatic control, and greater security, studies have shown a higher rate of completed suicide in the week following discharge. Patients lacking adequate support outside of a health care facility could be faced with more hardships upon discharge. Some could also view their illness as more debilitating when it requires a longer course of hospitalizations, leading to less adherence with the course of treatment.

A deeper understanding of patients’ suffering—especially through the view of the often-ignored psychodynamic lens—and early recognition of suicide risk factors specific to patients with schizophrenia are important in clinical settings. The effective intervention relies on detection and treatment tailored to each patient’s needs, rendering the healing journey more bearable and less challenging.

is an assistant professor in the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, and director of Community Psychiatry Clinics at the Harris Health System in Houston, Texas. 

is a medical student at the University of Balamand, Lebanon, who plans to pursue a residency in psychiatry. 

 is a clinical assistant professor at Baylor College of Medicine and a child, adolescent, and adult psychiatrist in private practice in Houston, Texas.

Psychodynamic Psychiatry in Clinical Practice. 5th ed

2. Lähteenvuo M, Batalla A, Luykx JJ, et al. 

Morbidity and mortality in schizophrenia with comorbid substance use disorders

3. Lingiardi V, McWilliams N, eds. Predominantly psychotic disorders. In: 

Psychodynamic Diagnostic Manual – 2nd edition: PDM-2

Predictors of suicide at time of diagnosis in schizophrenia spectrum disorder: a 20-year total population study in Ontario, Canada

Association of an early intervention service for psychosis with suicide rate among patients with first-episode schizophrenia-spectrum disorders

6. Acosta FJ, Navarro S, Cabrera B, Ramallo-Fariña Y, Martínez N. 

Painful insight vs. usable insight in schizophrenia. Do they have different influences on suicidal behavior?

How can looking at the suffering of patients with schizophrenia through a psychodynamic lens help clinicians develop effective interventions and treatment plans?

Shattered Self: Schizophrenia Suffering, Beyond Logic and Reason 

The National Suicide Prevention Lifeline will be the 911 for mental health. In July of 2022, it will have its own 3-digit code: 988. But do you think it will actually help prevent suicide? In your opinion:

If you have more to say on this subject, write us at 

The new 988 National Suicide Prevention Lifeline hopes to save lives, and we want to know your thoughts on it. 

Poll: What Are Your Thoughts on 988? 

In the previous 2 parts of this series on mHealth apps, we examined the barriers in access to care and what apps are available to assist in treatment of depression and 

. In this installment, we will cover the potential challenges and unintended consequences of utilizing this technology.

Unintended Consequences: Inaccurate Information and Self-Diagnosis

Apps of all kinds in the Android Google Play and Apple Store calculate ratings based on independent user feedback. User feedback is subjective and does not involve a review process or other rigor. An app may have a 5-star rating based on user feedback; however, this rating does not require any third-party verification of the quality, security, efficacy, or validity of the app.

 Given the lack of consistent oversight or regulation, there is no penalty for mHealth apps providing non-evidence-based and/or inaccurate information.

 A lack of reliable oversight means there is no verification of information quality. A study by Stawarz et al

 found that many of the apps with high user ratings had an inconsistent evidence base, demonstrating that priorities to the user that would translate to a higher app rating do not indicate solid validity and sound evidence.

Another potential challenge specifically with mHealth apps for 

 is that of patient self-diagnosis. Patients may self-identify that they are depressed, but in the absence of a full psychiatric evaluation by a trained mental health professional, they could very well meet criteria for a different condition that would require specific intervention and treatment tailored to that disorder. This can lead to negative treatment outcomes and misdirection of efforts supporting treatment of a condition that may not apply to a given consumer.

The clinical utility and efficacy of the data provided within these apps is an important consideration. Currently there is no formal review process for mHealth apps, and that has been an 

. The existing medical research on apps is not very robust, and it is quite far behind relative to how widely mHealth apps are utilized.

 With the existing research being so limited, another factor to consider is that the studies that exist often include very small sample sizes.

 Research conducted on these apps also tends to be short in duration, without longer-range follow-up to evaluate outcomes.

Security of patient data is an important consideration within the context of using mHealth apps for depression. Protected Health Information (PHI) breaches are reported on the news nationally and worldwide every day. All breaches, whether large or small, have the potential for significant impact for individuals, communities, and larger populations. An in-depth study of some mHealth apps found that there was transmission of medical data via unsecured processes, and that privacy policies were lacking relative to the kind of information being obtained from individuals.

The aim of a cross-sectional study by Tangari et al was to evaluate the collection of user data within mHealth apps, and to review the privacy practices of apps and potential risks to customer information.

 It was noted that amongst the top mHealth apps, privacy disclosures to the app user was consistently inadequate. The evaluation of privacy and security of these apps is complex and multifactorial. See the 

 for an overview of the components addressed in the security review of apps.

In the study by Tangari et al, 665 different third parties were identified as being able to access patient information contained within the apps.

 It was noted that a list of some specific third parties had accessed the most data—more when compared with the rest of the third parties obtaining this information. The vast majority of the apps reviewed were able to obtain and share personal information of the apps’ users. The review found that many privacy policy links did not work or were not reliable.

There is significant concern related to patient safety, especially when one’s symptoms are severe and amidst the presence of suicidal thoughts or actions. In the Martinengo et al

 review of suicide prevention apps, the findings demonstrated that none of the apps assessed patient risk or protective factors, or triggers; only one of the evaluated apps inquired about prior history of 

. Individuals with a history of previous self-harm are at a substantially increased risk of suicide when compared with the general population.

 are important, complex processes conducted by highly trained, skilled clinicians in psychiatry and related fields. Evaluating patient risk is complex, even for the most skilled and experienced provider with years of training and expertise in the field. There are numerous risk factors for suicide, and yet the reality of the outcomes of suicide is far more nuanced and complex beyond a list of these potential contributing factors. Significant risk factors for suicide include but are not limited to: prior history of self-harm or suicide attempt,

 family history, psychiatric illness, recent personal loss, and 

, along with other demographic and social factors.

Safety planning is an important tool used by mental health clinicians to work with patients who are dealing with suicidality when these patients are not at an acute phase of requiring inpatient hospitalization. In the review of suicide prevention apps, only 10% the depression apps and only 52% of suicide prevention apps that were reviewed utilized templates to support development of a safety plan for the app’s users.

 Only 4 of the apps reviewed allowed users to share the safety plan with a trusted member of their support system.

Of the 46 suicide prevention apps, only 20% provided users with emergency access to trained mental health care professionals via the app.

 Of the depression management apps reviewed, 24% provided app users with direct access to a crisis line through the app. However, when the crisis contact information was verified during the review process, 9% of the crisis contact information in these apps was incorrect.

Some of the suicide prevention apps utilize chatbots.

 work by identifying key words and phrases to trigger subsequent responses based on various algorithms. In the apps utilizing chatbots, a very concerning statement from a patient stating that they are “sad” and “hopeless” did not prompt a follow-up question that would be triggered by a “worrying statement,” when, in fact, the aforementioned statement is quite concerning and would warrant further evaluation and clinical intervention.

There are unintended consequences of mHealth apps for depression as they exist currently. A lack of external validity measures and exclusive use of user review ratings does not provide patients with information regarding the evidence base or efficacy of content provided within the app. As health care providers, our role is to translate evidence base into terms that patients can understand; the provider may be tasked with trying to do this, but given the aforementioned concerns, providers may be reluctant to do so. A potential opportunity to improve upon this would be facilitating collaboration and partnerships between academic and medical institutions for app development. With the knowledge base and the intimate awareness of security and privacy, these collaborations would be able to facilitate creation of an app that is evidence-based, externally validated, and suitable for use as a tool in collaboration with the 

Privacy of collected data is an additional concern that is not unique to mHealth apps. There is a noted lack of transparency on the part of apps to provide a clear explanation to app users regarding how their data is collected and potentially shared.

 Ideally, the accountability for these policies should be placed on the individual app companies, with some standards and regulation by the app stores that are publishing the tools.

Best Practices to Support Care Using Patient-Facing Technology

To continue to facilitate mHealth apps that are effective, safe, and useful for patients, there are actions that can be taken to strengthen the aforementioned factors and to address some of the concerns outlined previously within this series.

A standardized, external review tool to validate apps would be a helpful framework to provide some added accountability and verification of app content. A tool discussed in one of the reviewed papers is the 

 (MARS), which seeks to confirm interrater reliability and consistency using 2 expert raters to evaluate based on a 23-item scale.

 This scale, like others that have been explored, lacks clear validity and has not been widely utilized to further evaluate its validity and efficacy. Including quality measures in App Store ratings or reviews that have been conducted by field experts, in addition to the existing system of exclusively customer review ratings, would be another way to potentially increase the accountability required for mHealth apps.

As the sheer number of mHealth apps being used to treat depression is expansive and potentially overwhelming to health care providers, further research and review may help guide the 

 and support those who choose to recommend or discuss app use with tehir patients as an adjunct to professional care. Using an evaluative tool such as MARs would provide health care providers with a more efficient way to be able to further encourage or perhaps redirect patients from the use of certain apps to support their mental health.

Ensuring that patients are informed consumers and aware of how their information is being used is imperative. App developers should be transparent in the writing and sharing of privacy policies, and further oversight regarding third-party sharing should be prioritized on a higher national level to remove some of the onus from the individual and to ensure that developers and corporations are accountable.

A best practice would be for supportive app tools to be encouraged when clinically appropriate, with clear guidelines that they are not a replacement or substitution for clinical care. This would be something for the patient and provider to approach as part of collaborative, patient-centered care. There are disclaimers that app users need to acknowledge in order to use these apps, but there should be ongoing check points and redirection to a trained mental health care professional beyond just an initial acknowledgment when first using the app.

With the rapid influx of new technologies, there are many benefits and unintended consequences in the use of mHealth apps in mental health care, there is also a potential role and benefit for well-done mHealth apps to address mental health, and specifically depression and suicidality. However, as a standalone intervention, mHealth tools are not reliable for managing these complex and potentially life-threatening conditions.

 The treatment of depressed and suicidal patients requires a collaborative, team-based approach including the patient, family, friends and a skilled mental healthcare provider in the utilization of different treatment modalities.

There are aspects of existing mHealth apps that may be ineffective, but more importantly there are components that can be potentially harmful. For example, almost 10% of the crisis hotline phone numbers in the apps reviewed by Martinengo et al

 were incorrect. Without a more comprehensive review process or verification mechanism, that kind of error can have potentially serious consequences. Additionally, this lack of oversight or guidance places the onus on individual health care providers and patients/app users. This may further impede the ability to make progress in this modality. Health care providers may be fearful of 

, which may steer providers away from considering the incorporation of app use into their practice.

There are significant and seemingly endless opportunities for how these apps can potentially be utilized to benefit patients and providers, provided this occurs in a safe and evidence-based manner with consideration for privacy of patient information. Ongoing research is needed, along with policy to encourage and promote safe app development and use, and clear, realistic outcomes associated with the app.

is a psychiatric-mental health nurse practitioner in the Seacoast, New Hampshire area, and a clinical assistant professor and program director of the Post-Masters Psychiatric-Mental Health Nurse Practitioner Certificate Program, Department of Nursing, University of New Hampshire, Durham.

 is a Clinical Associate Professor and Director for the Direct Entry Master’s in Nursing, Evidence-Based Nursing and Clinical Nurse Leader programs at the University of New Hampshire, Durham. Her research interests include the use of Health Information Technology such as mHealth in support of health equity initiatives.

Interrater reliability of mHealth app rating measures: analysis of top depression and smoking cessation apps.

2. Martinengo L, Van Galen L, Lum E, et al. 

Suicide prevention and depression apps’ suicide risk assessment and management: a systematic assessment of adherence to clinical guidelines.

3. Stawarz K, Preist C, Tallon D, et al. 

User experience of cognitive behavioral therapy apps for depression: an analysis of app functionality and user reviews.

4. Munoz Ramos R, Ferrer Cheng PG, Jonas SM. Validation of an mHealth app for depression screening and monitoring (psychologist in a pocket): correlational study and concurrence analysis.

Ehealth interventions for the prevention of depression and anxiety in the general population: a systematic review and meta-analysis.

6. Tangari G, Ikram M, Ijaz K, et al. 

Mobile health and privacy: cross sectional study. 

Predicting suicide following self-harm: systematic review of risk factors and risk scales. 

8. Stern TA, Rosenbaum JF, Fava M, et al. 

Massachusetts General Hospital Comprehensive Clinical Psychiatry

Learn what potential challenges come with mHealth apps and how to overcome them to best fit patient needs. 

Challenges with mHealth Apps for Depression and Suicide Prevention 

The American Academy of Pediatrics and American Foundation for Suicide Prevention (AFSP), together with experts from the National Institute of Mental Health, created an educational resource to support pediatric health clinicians and other health professionals in identifying strategies and key partnerships to support youth at risk for suicide: the Blueprint for Youth Suicide Prevention.

™ sat down with Christine Yu Moutier, MD, the Chief Medical Officer for the AFSP.

 (PT): The Blueprint for Youth Suicide Prevention is the first major interdisciplinary effort to infuse suicide risk reducing strategies into pediatric care and youth community settings. How do you want this to help child and adolescent psychiatrists and mental health professionals? How can child & adolescent psychiatrists support this initiative?

The Blueprint provides steps for primary care pediatric health providers—ideally working alongside child and adolescent psychiatrists and other mental health professionals—to engage in suicide preventive actions in the health care settings where children and teens receive routine health care. Pediatricians are very trusted resources for families and medical settings are well-positioned to identify changes in mental health and screen for common conditions such as depression, anxiety, substance use problems, and eating disorders. All of these current efforts can be extended to specifically screen for suicide risk and provide education, support, and resources to patients and families.

Suicide is the second leading cause of death in youth and young adults, aged 10 to 24 years and many young people that die by suicide visit a health care provider in the months or weeks prior to the death—

38% of adolescents had contact with a health care system within the 4 weeks before their death

34% of people 15 years of age and older had contact with a health care provider in the week before their death

That is why health care systems are a critical setting to identify youth at-risk for suicide and coordinate suicide prevention strategies that can have a dramatic impact on saving lives. The Blueprint for Youth Suicide Prevention can help psychiatrists and other mental health professionals address youth suicide prevention via care delivery, identify and remove common barriers for patients who need care and support, as well as implement strategies for integrating suicide prevention within the larger health care system.

Health system leadership and staff can protect youth mental health by considering the following clinical suicide prevention approaches:

-Risk identification, screening, and assessment;

-Indicated interventions, including safety planning and lethal means counseling for youth with suicidal ideation or behavior;

-Treatment such as the use of medications, more health care visits, or referral to evidence-based suicide risk reducing treatment; and

-Recovery including support systems that help individuals maintain progress, encourage posttraumatic growth, and find meaning and purpose.

PT: We know that minority youth are at an increased risk for suicide. In the Blueprint, a key takeaway is that health equity is critical to suicide prevention. Can you tell us more about that? Furthermore, what is the difference between equity and equality?

 In recent years, we have learned so much about the ways structural racism and health inequities have been long affecting the mental health and suicide risk of minoritized communities. For example, 

 shows experience(s) with discrimination impacts youths’ risk for suicidal thoughts and access to developmentally and culturally responsive mental health services is limited in many communities, clinics, and schools.

 Yet there is little research that explores suicidal thoughts, behaviors, and risk factors among LGBTQ2S+, American Indian, Alaska Native, Black, and Latinx communities nor the impact racism, historical or intergenerational trauma has on suicidal ideation.

Clinical suicide prevention efforts are needed to provide comprehensive, effective, and culturally appropriate care to youth populations, including: 

child welfare system or who have experienced family disruption

, and youth with special care needs such as 

Health equality assumes everyone can attain or reach their full potential if given the same resources when it comes to their health. However, we know that people are not at the same starting line and need different supports to reach their optimal health at a personal, community, and system level. That is why it is even more crucial we strive to achieve health equity. This involves reducing long-standing socioeconomic, cultural, and other barriers for medically underserved communities to receive the comprehensive, effective, and culturally appropriate care and treatment they need.

PT: Right now, there is a lot of legislation targeting the LGBTQ+ community (the “Don’t Say Gay” bill in Florida, and the anti-transgender directive in Texas). Do you think legislation like this will have an impact on rates of LGBTQ+ suicide? Are the upward trends of suicide in youth similar for LGBTQ+ youth as they are for cis youth?

 At the American Foundation for Suicide Prevention (AFSP), we are concerned. For many years, AFSP has funded research related to LGBTQ2S+ experiences and their potential impact on both suicide risk and protection. We also have taken strong positions in the policy arena when research supports a connection to suicide risk, such as our work across many states to ensure that conversion therapy is not accessible to minors. AFSP stands with the consensus of every major health organization and supports bans on practicing conversion therapy on minors.

Suicide most often occurs when stressors and health issues converge to create an experience of hopelessness and despair. For LGBTQ2S+ youth in particular, stigma, prejudice, and discrimination can increase the likelihood of stress, depression, traumatic experiences, violence, and serious mental health concerns. Conditions like depression, anxiety, and substance problems, especially when unaddressed or when people lack access to quality mental health care, pose a greater risk for suicide.

During the pandemic, we have seen more pro-mental health and suicide prevention legislation pass at federal and state levels, thanks to the 40,000 volunteer field advocates with AFSP and our colleague organizations like NAMI, MHA, Jed Foundation, and Trevor Project all raising our voices together. This reflects investments in research demonstrating effective strategies, combined with the voices of people with lived experience and suicide loss, clinicians and people from all walks of life joining in the incredible mental health and suicide prevention movement. However, it is our individual and collective responsibility to continue supporting the mental health and wellbeing as well as prevent suicide amongst LGBTQ2S+ youth, especially in light of legislation like Don’t Say Gay that restrict discussion of sexual orientation and gender identity in public schools and are harmful to LGBTQ2S+ youth mental health.

PT: The Blueprint stresses the importance of a collaborative care, multi-layered model. Will you talk a little more on why it is imperative that psychiatrists, primary care physicians, teachers, parents/guardians, and all clinicians caring for the child need to work together to prevent suicide?

Suicide risk involves a complex set of factors at the individual, community, and societal levels. Child and adolescent psychiatrists as well as other mental health professionals understand the unique ways in which mental health impacts various stages of development in youth. This expertise can be extended beyond the clinic through a team-based, collaborative, and integrated care model by engaging schools and local communities in youth suicide prevention initiatives.

Youth face barriers in their school and local community due to a variety of social factors, community resources, as well as systemic racism and discrimination. They also face barriers when it comes to mental health support. That is why it is crucial for schools and community partners to work together to understand the resources and care systems available in their local community so pediatric health clinicians can best support mental health amongst youth based on where they live, learn, work, and play.

PT: In screening young patients for suicide, risk may be difficult to properly gauge with a parent/guardian in the room, as the patient may be less open in their responses. If the parent/guardian refuses to leave the room, what would you recommend to the screening psychiatrist?

There are strategies clinicians are well versed in, in order to have private 1:1 conversations with children and teen patients. This issue is very relevant to sensitive conversations about suicidal thoughts and feelings surrounding this level of distress. The need for a nuanced approach to these sensitive conversations is addressed in the Youth Suicide Prevention Blueprint as seen in the section on 

PT: How is screening for suicide via telehealth different than in person including how it should be done as well as the efficacy of the screening?

Many communities lack sufficient access to mental and behavioral health support. When traditional in-person mental health care appointments are unavailable, clinicians can help individuals and families consider alternative options like telehealth. Telehealth is an effective, convenient alternative to in-person screening, as it is mobile-friendly and uses multiple languages, interpreters, and assistive technologies to facilitate visits. It also has similar reliability and accuracy to in-person screening.

The patient, their family, and provider should determine together if telehealth is the appropriate modality for screening, if in-person is preferred, or if a hybrid approach will meet the child’s mental health care needs based on the nature or complexity of the child’s mental health condition, comfort level with telehealth, and ease of access.

For those who may not have access to telehealth capabilities, other resources such as a school psychologist, social worker, and/or other community-based resources are available. That is another reason why teachers, parents/guardians, and clinicians working together is imperative to preventing youth suicide.

Speaking of telehealth resources, all pediatricians should be aware of a wonderful resource available in many states, thanks to the incredible dedication of Pediatric Mental Health Care Access (PMHCA) Programs, sometimes referred to as Child Psychiatry Access Programs (CPAPs). These are programs that provide timely training and support to pediatric primary care clinicians (PCCs) and other clinicians related to detection, assessment, treatment, and referral of behavioral health conditions within their practice. This support is provided as part of a peer-to-peer, telehealth-based consultation model—PCCs can connect with off-site child/adolescent behavioral health professionals by phone, video call or email/web-based consultation. You can find more information on increasing access to behavioral health care via telehealth 

PT: We have all heard the myth that bringing up topics like suicide will “put the idea in their heads.” Can you talk about why that is untrue? Do myths like this encourage stigma?

 People may think if “I ask if someone if they are suicidal, I will put the thought in their head” or “I’m going to increase risk,” because they have heard of the concept of suicide contagion, which stems from unsafe messaging that sensationalizes suicide and details suicide methods through media, social media, or other key moments of messaging. However, asking how an individual is feeling and if they are having thoughts of suicide in an open, caring manner has clearly not been shown to increase risk, and actually is thought to open up potentially game-changing dialog that may be the first step in getting professional treatment. When you ask someone about suicidal thoughts directly, it provides them with the opportunity to share what may have been not disclosed. And often times, suicidal thoughts being held in secret and never having the opportunity for processing, support or treatment, is thought to lead to worse outcomes including suicide risk.

In the past, before a body of scientific research led to an understanding of what drives suicide risk, many myths prevailed. This led to stigma and erroneous views of suicidal behavior resulting in harshly punitive ideas and judgment of people who experience suicidal thoughts, attempt suicide, or ultimately lose their lives to suicide. Now that a multidisciplinary group of scientific fields are shedding light on the actual drivers of suicide risk, cultural views are changing and bringing an understanding that while complex, suicide is a health issue.

PT: This Blueprint was developed at the Virtual Summit on Youth Suicide Prevention. Is there anything you’d like to highlight from the Summit?

 The Youth Suicide Prevention Summit was an incredible convening of over 100 experts including pediatricians, suicide experts, youth organization and school leaders, people with lived experience, and researchers over 3 days! It was moving in the level of engagement and dedication shown across every sector of society from health to education to juvenile justice. We also held 2 subsequent convenings—1 focused on the role of government agencies some of whom had never seen themselves as having a role in suicide prevention, and 1 focused on equity and minoritized youth, both of which had extremely high levels of engagement and sense of urgency. We are so grateful to ALL who gave of their time and expertise in developing the Blueprint, and those who will engage in the implementation of these potentially life saving actions.

To see more of Dr Moutier’s thoughts on suicide, see 

Breaking the Trend: New CDC Data on Suicide

is chief medical officer of the American Foundation for Suicide Prevention, New York, NY.

1. Suicide: Blueprint for Youth Suicide Prevention. American Academy of Pediatrics, American Foundation for Suicide Prevention, National Institute of Mental Health. 2022. Accessed March 9, 2022. 

https://www.aap.org/en/patient-care/blueprint-for-youth-suicide-prevention/

2. Ahmedani BK, Simon GE, Stewart C, et al. 

Health care contacts in the year before suicide death.

3. Laanani M, Imbaud C, Tuppin P, et al. 

Contacts with health services during the year prior to suicide death and prevalent conditions a nationwide study.

4. Madubata I, Spivery LA, Alvarez GM, et al. 

Forms of racial/ethnic discrimination and suicidal ideation: a prospective examination of African-American and Latinx youth.

5. The Congressional Black Caucus. Ring the alarm: the crisis of Black youth suicide in America. Emergency TaskForce on Black Youth Suicide and Mental Health. Accessed March 15, 2022. 

https://watsoncoleman.house.gov/uploadedfiles/full_taskforce_report.pdf

6. American Indian and Alaska Native populations. Suicide Prevention Resource Center. Accessed March 15, 2022. 

https://sprc.org/scope/racial-ethnic-disparities/american-indian-alaska-native-populations

7. Vargas SM, Calderon V, Beam CR, et al. 

Worse for girls?: gender differences in discrimination as a predictor of suicidality among Latinx youth.

Risk factors of suicide and depression among Asian American, Native Hawaiian, and Pacific Islander youth: a systematic literature review.

9. Estimate of how often LGBTQ youth attempt suicide in the U.S. The Trevor Project. March 11, 2021. Accessed March 15, 2022. 

https://www.thetrevorproject.org/research-briefs/estimate-of-how-often-lgbtq-youth-attempt-suicide-in-the-u-s/

10. Fontanella CA, Hiance-Steelesmith DL, Phillips GS, et al. 

Widening rural-urban disparities in youth suicides, United States, 1996-2010.

11. Ivey-Stephenson AZ, Crosby AE, Jack SPD, et al. 

Suicide trends among and within urbanization levels by sex, race/ethnicity, age group, and mechanism of death — United States, 2001–2015.

Suicide and suicide attempts in children and adolescents in the child welfare system.

13. Abram KM, Choe JY, Washburn JJ, et al. Suicidal thoughts and behaviors among detained youth. 

https://ojjdp.ojp.gov/sites/g/files/xyckuh176/files/pubs/243891.pdf

14. Rybczynski S, Ryan TC, Wilcox HC, et al. 

Suicide risk screening in pediatric outpatient neurodevelopmental disabilities clinics.

The Chief Medical Officer for the AFSP sat down with Psychiatric Times to talk about the new Blueprint for Youth Suicide Prevention. 

The Blueprint: Strategizing and Partnering to End Youth Suicide

In a 2016 review, there were more than 165,000 mHealth apps available to patients on the market.

 A review published just 3 years later noted the availability of 259,000 mHealth apps worldwide.

 Of the rapidly evolving app market, mHealth apps are among the fastest-growing groups, with an annual estimated growth rate of 32.5%.

 mHealth apps focused on mental health are one of the most prominent categories.

 These apps can be obtained for numerous device types and through the Apple iTunes/App Store or Android Google Play App Store.

There is currently no standardized review process to evaluate mHealth apps for quality or accuracy of information.

 There are also no centralized repositories for app reviews and ratings, and no type of standard app rating process or procedure.

 Current rating systems are based solely on app user ratings, which often are focused on design, interface, and usability. The evidence base of the information contained in these apps is not externally reviewed or verified as part of a requirement of implementing an app and getting it on the market.

 Relatively few apps have been through the rigor of a clinical trial.

The United States Food and Drug Administration (FDA) does not offer guidance for mHealth apps, and the FDA has indicated no plans to begin to regulate apps, especially as the FDA has deemed many to be 

 Between the FDA and European regulatory bodies, only 8 mental health apps have been approved.

 The FDA provides minimal guidance related to the post-market management of medical devices, which include mHealth apps, to consider risk management and utilize necessary steps to secure patient information.

 However, there is a lack of ongoing guidance and regulation in this area for app developers to utilize. There is also a lack of clear, consistent privacy policies and transparency with app users about how their information may be used and transmitted to third parties.

 continues to increase. There have been several approaches and foci for these apps. Some of the existing mHealth apps on the market related to depression include a focus on preventing depression, screening for depression, and supporting treatments with depression; there is even a 

 Currently there is no guidance, position statement, or even clear guidelines related to mHealth apps addressing psychiatric conditions from major national professional organizations such as the American Psychological Association and the American Psychiatric Association.

The mHealth apps are not consistently included in the same categories of the app store; some are listed in “Health and Fitness” categories, whereas others are indicated to be within the “Medical” category.

 Studies reviewing health app quality have found that apps are not consistently utilizing evidence-based clinical information or verified decision support tools.

How can these mHealth apps help in the treatment of depression? 

Suicide

Shattered Self: Schizophrenia Suffering, Beyond Logic and Reason

Poll: What Are Your Thoughts on 988?

Challenges with mHealth Apps for Depression and Suicide Prevention

The Blueprint: Strategizing and Partnering to End Youth Suicide

Treating Depression and Preventing Suicide: The Impact of mHealth Apps

Psychiatry for Primary Care: Suicide Risk Assessment and Prevention (Part 3)

Psychiatry for Primary Care: A Behavioral Medicine Update (Part 1)

Researchers Address Youth Suicide Prevention in Virtual Panel

Remembering Daughters and Suicide

Grief After Suicide