The Science of Suicide Prevention, with Matthew Nock, PhD

The U. S. suicide rate today is almost identical to what it was a century ago, even as death rates from many other causes have dropped. Matthew Nock, PhD, of Harvard University, discusses why it’s so hard to predict who will act on suicidal thoughts -- and when; how new tools, from electronic health records to smartphone sensors, are helping researchers understand risk in real time; what interventions show the most promise; why stigma and fear keep us from discussing suicide; and why open conversations are key to prevention. Learn more about your ad choices. Visit megaphone.fm/adchoices

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:00Kim Mills?

  Before we begin today's episode, please be aware that we will be discussing suicide and mental health struggles. If you or someone you know is struggling or in crisis, help is available. You are not alone. Call or text 988 or go to 988lifeline.org to reach the suicide and crisis lifeline. Services are free, confidential, and available 24/7. Each year, nearly 50,000 Americans die by suicide, and suicide is the second-leading cause of death among people ages 15 to 34, according to the American Foundation for Suicide Prevention. Many millions more experience suicidal thoughts, and one of the biggest

• 0:45Kim Mills?

  challenges in suicide prevention is figuring out who is most at risk and when that risk is greatest. Researchers have spent decades trying to answer those questions, but suicide remains difficult to predict. Now, though, new technologies and research methods are giving scientists new ways to study suicide risk in real time. So why is it so hard to predict who will attempt suicide? And how are new technologies changing what we know about suicide risk and prevention? What interventions are available to help? And what can you do if you're worried about someone in your life? Welcome to Speaking of Psychology, the flagship podcast of the American Psychological Association

• 1:29Kim Mills?

  that examines the links between psychological science and everyday life. I'm Kim Mills. My guest today is Dr. Matthew Nock, the Edgar Pierce Professor of Psychology at Harvard University and co-director of the Center for Suicide Research and Prevention at Harvard and Mass. General Brigham. His research aims to advance our understanding of why people behave in ways that are harmful to themselves, with an emphasis on suicide and other forms of self-harm. He uses a range of methods, including epidemiologic surveys, lab-based experiments, and clinic-based studies to better understand how these behaviors develop,

• 2:12Kim Mills?

  how to predict them, and how to prevent them. His work has been funded by grants from the National Institutes of Health and several private foundations, and has been published in more than 300 scientific papers and book chapters. In 2011, he was awarded a MacArthur Fellowship, also known as a Genius Grant. Dr. Nock, thank you for joining me.

• 2:31Speaker 01

  Thank you so much for having me on, and thanks for covering this topic as well. Really appreciate it.

• 2:35Kim Mills?

  Absolutely. It's very important. And I want to start by saying, I read a quote from you saying that the suicide rate in the US hasn't really budged in 100 years, although we've made great progress against many other leading causes of death. So let's start there. Why is it so hard to predict and prevent suicide?

• 2:53Speaker 01

  Yeah, that's a great question. And if I can, I'll qualify the quote a little bit. The suicide rate now, in this year, is virtually identical to what it was 100 years ago. So that's the big top-line finding. The rate does ebb and flow. So if you read newspapers, you'll see, well, the suicide rate has gone up the past 20 years. Sure, but it went down the 20 years before that. So I think, zooming out, I think what's most striking for me is, the rate hasn't really changed. And if you look at other leading causes of death, heart disease, cancers, pneumonia, tuberculosis, motor vehicle accidents, the mortality rate for each of those has plummeted in the past 100 years. Not so for

• 3:34Speaker 01

  suicide. So that's the big, I think, important contrast. Why is that? I think the reason is, for all of those other causes of death, we've paid a lot of attention to them, we've allocated funding and significant scientific efforts to try and understand them and predict them and prevent them, and we've translated those findings into action. There's huge campaigns decades ago for wearing seat belts. We talked a lot more about motor vehicle accidents and the importance of wearing seat belts, and people wear them a lot more now, and people die less from motor vehicle accidents. HIV/AIDS came on, and we didn't cure it, but we developed amazing interventions that now decrease suffering and increase length of life. Not so for suicide. We haven't had the same advances. And for me, that's the

• 4:19Speaker 01

  thing we really need to talk about and focus on. And I think it's largely because of stigma, that it's still, people are still afraid to talk about suicide, to focus on suicide, and do the things that are required to make the same changes in this area. So all the more reason I'm glad that this podcast is focusing on this topic, just trying to be part of the solution.

• 4:39Kim Mills?

  How common are suicidal thoughts, and what percentage of people who think about suicide actually attempt it?

• 4:46Speaker 01

  Yeah. When we do surveys, or we find a large representative sample of the population and ask, have you ever in your life had serious thoughts of suicide? Around the world, 9% of people say, yes, I have. In the US, that number is about 15%. So 15% of people in the US say, at some point in my life, I've seriously considered ending my life. Pretty consistently, around the world, a third of people who have that thought will actually make a suicide attempt. So it's 3%. Globally, 5% in the US. And that ratio is pretty consistent. A third of the people who think about suicide will make an attempt. Two-thirds won't. So

• 5:29Speaker 01

  just having suicidal thoughts is not destiny. Suicidal thoughts are especially common in young people. When we do surveys of US high school students, anonymous surveys, so we had a higher yes rate on them because there's not fear of being found out and intervened upon, about 20% of high school students in the US say, in the past year, I've thought about killing myself. So 1 in 5 of our young people in high school are having these thoughts. So they're not so uncommon developmentally. But it's the acting on them that's rarer. But it's pretty, you know, pretty common, if it's 5%, 5% of the time.

• 6:06Kim Mills?

  And is that a pretty steady number with young people, or has that changed over time?

• 6:11Speaker 01

  It's fairly steady. In the past 10 years or so, the numbers from surveys of high school students, some of these rates have ticked up a little bit. So from 2013 to 2023, the rate of high school students saying that they're really sad or hopeless has increased over those 10 years from 30% to 40%. The number of students saying they have seriously considered suicide has increased from 17% to 20%. So they're ticking up slightly over the past decade. They're especially high in girls. Females consistently have higher rates of suicidal thinking and non-lethal suicidal behavior. Those identifying as LGBTQ+

• 6:54Speaker 01

  about 40% say that they've had thoughts of suicide in the past year, so especially high rates. And that gender ratio flips for suicide death. Men are four times more likely to die by suicide than are women. And that's true in the US, and it's true in every country around the world.

• 7:11Kim Mills?

  And is that because they just tend to use more lethal methods?

• 7:15Speaker 01

  Yeah, that's the thinking, that men are more likely to use firearms and similarly lethal methods, whereas women are still more likely to die by firearms as a method. That's the most common one in the US, but are more likely than men to use less lethal methods, overdose and so on.

• 7:32Kim Mills?

  Right. Now, we know that things like previous suicide attempts, mental illness, and substance use are associated with suicide risk, but how good are those factors at predicting what an individual person will do?

• 7:46Speaker 01

  They're not great. One of the biggest take-homes from suicide research is, over the past 50 years, we've identified a lot of risk factors for suicidal, let's say, thoughts, attempts, and death. Factors that, by their presence, are associated with an increased risk of suicidal outcomes. The difficulty is going from knowing that something is a risk factor, to figuring out who's at risk and when they're at risk, and being actually able to predict and prevent the outcome. Take mental disorders as an example. Studies have shown that 90 to 95% of people who die by suicide had a prior diagnosable mental

• 8:27Speaker 01

  illness. Not diagnosed, diagnosable. It was present, it might or might not have been identified. Well, that's great. So we know that most people who die by suicide had a mental illness. Well, most people with mental illness don't die by suicide. So just knowing that someone has depression doesn't tell us, for instance, whether that person is going to think about suicide, whether that person's going to make a suicide attempt, in what year are they going to do so, in what month, in what week. So for intervention purposes, knowing that a person has risk factors is useful, but where the rubber hits the road, it's much more challenging to convert that into action and prevention.

• 9:04Kim Mills?

  Are the predictors of suicide different for different groups of people? In other words, are they different for adolescents versus young adults versus older folks? And if so, how?

• 9:17Speaker 01

  There are some differences, but there's a lot more commonalities than there are differences. So we've looked at suicidal behavior in children, adolescents, adults, older adults, Army soldiers, military veterans, college students, people in, at this point, over three dozen countries from around the world as part of this WHO initiative, the World Mental Health Survey. And what's, I think, most striking is just the consistency. Mental disorders are important everywhere we look and every population we look at. Depression is the disorder people think most about when they think about suicide. It seems to consistently be useful for predicting whether a person has thoughts of suicide,

• 9:58Speaker 01

  but not who acts on those thoughts. What predicts acting on the thoughts, in terms of mental disorders, are disorders characterized by anxiety and poor behavioral control, intermittent explosive disorder, substance use disorders, and so on. This is true in young people, it's true in adults, it's true in military service members, it's true in veterans, and so on. So there's a lot of commonalities. There are differences. As you might expect, people in the Army, for instance, have combat-related risk factors that just don't generalize to other groups. For adolescents, having siblings in the home, multiple parents in the home seems to be protective, less of an issue for older people. So there are some differences that, around the edges, can help us tailor prediction models. But I would

• 10:41Speaker 01

  say the big finding here is just the consistency across all the different groups that we look at. And one thing I want to, not related to any specific risk factor, but I want to say a little bit about what we know about why people die by suicide, to help make sense of some risk factors. And for me, this is really helpful, and talking to people at risk and families, it's helpful. When we do qualitative interviews, we sit down and interview people who have tried to kill themselves after the initial, you know, emergency of the situation has passed and they're, they're in a state where we can talk to them and interview them. And we say, why did you try and kill yourself? Far and away, the most common reason people give about 90% of the time is I wanted to escape some seemingly intolerable circumstance, whether it was how I was feeling, thoughts

• 11:26Speaker 01

  I was having, a social situation, interpersonal situation I thought I was in. There's a significant psychological pain that a person's experiencing, a narrowing of perspective in time and in options, and an idea that the only solution I have available to me is trying to end my life to get out of this situation. And that's what we're really trying to wrestle with and understand. So when you ask about risk factors, when I think about risk factors, I think about depression as helping to create the psychological pain that a person wants to escape from. And those other, you know, impulse control related factors that predict attempt, helping to generate action in a person when they're in this state of psychological pain. So for the listener, I would, if you're trying to make sense of, well, why do people think about suicide? Why do they try and die by suicide?

• 12:11Speaker 01

  It is the vast majority of the time about trying to escape from some seemingly intolerable, let's call it psychological pain.

• 12:19Kim Mills?

  How do most clinicians assess the risk of suicide? I mean, what kinds of questions do they ask or should they ask? And how do they weigh the different pieces of information and make decisions about, say, somebody who should be hospitalized and somebody who shouldn't?

• 12:35Speaker 01

  Yeah, that's a fantastic question. And it's actually, those are the exact questions we just asked in a qualitative study that we did with, with frontline clinicians. And we asked, almost verbatim to what you just asked, we asked, how do you assess suicide risk? So if someone's, if someone's having thoughts of suicide, what we encourage people to do is bring that person to an emergency department or call 911 or call 988, the, in the U.S., the national free anonymous hotline. And when you get to, let's say, the emergency department, for those who aren't familiar, what happens if you're, if you're having thoughts of suicide? You meet with the clinician, just like you would if you had a cut or, or a broken, broken wrist or something.

• 13:16Speaker 01

  You meet the clinician and they ask you questions to try and understand your mental state and to try and make an accurate assessment of whether you are at imminent risk for hurting yourself or potentially hurting someone else, or if you're unable to care for yourself, the sort of standard criteria for determining whether you need a higher level of care, hospitalization and so on. And so we are doing research, trying to understand, well, what are clinicians naturally asking to make those determinations? And we haven't fully finished analyzing our results and we haven't published any yet, but I can share that there's great variability in the questions that clinicians are asking to try and understand suicide risk.

• 13:58Speaker 01

  And there's some variability in how clinicians are making determinations about who requires or might be expected to benefit from hospitalization. On one hand, it might be surprising, shouldn't we have a standard way of doing this and everybody asks the same questions? And there are some standards. There's standard scales that people use to assess for the presence of and severity of suicidal thinking. But clinicians are doing a lot of asking of questions and case conceptualization outside of that. And it's not surprising then that there's great variability, given the breadth of risk factors. There's dozens of risk factors for suicide. So how's, and the, and the scales that are standard, don't ask about all those risk factors. So there's a lot of space there for clinicians to ask a lot of different questions.

• 14:43Speaker 01

  And if you think about, you know, who should be hospitalized, there's a lot that goes into that beyond risk. It's not just, is this person at risk for suicide? It's, are they in treatment? Do they have a treatment team outside the hospital that can help keep them safe? What's their family situation? Do they have family members who are working closely with them to try and ensure their safety and improve their, their psychological health? Are they stably housed? Have they benefited from hospitalization in the past? So there's a lot of factors that might go into making a decision about hospitalization. It's not such a simple cut and dry thing. There's also exciting new research that came out last summer by Ron Kessler, who is a leading psychiatric epidemiologist at Harvard Medical School, on the benefits of hospitalization

• 15:27Speaker 01

  for those at risk for suicide and the variability in outcomes for people who are hospitalized. And this is going to be cartooning it a little bit, but what he and his team found is it seems that not everybody benefits from hospitalization for, for suicide risk, perhaps not surprisingly. There's been a lot, a lot of debate about whether hospitalization is effective or not. And that's a, a difficult experiment to do because we don't want to not hospitalize people who we think are at risk just to do an experiment. What his study found is that for about half of people, it seems to not make a difference whether they were hospitalized or not in terms of their risk. For about a quarter of people, they seem to get much better after a hospitalization.

• 16:10Speaker 01

  For about the other quarter of people, they seem to do worse after a hospitalization. So maybe it is the case that what happens in a hospital, if you're at risk for suicide, intense psychotherapy, some medication management, maybe is helpful for some people. They really benefit from that higher level of care in the short term. For some people, it doesn't make a difference. For some people, maybe it gets, they get worse in some way. We don't know why, we don't know the mechanism yet, and this requires replication and so on. But it's an exciting step forward in starting to think really critically about what is it that we do when someone's at really high risk? And it doesn't seem to be the case that everyone's going to benefit by more care or everyone's going to benefit from what we do in, let's say, a hospitalization.

• 16:52Speaker 01

  And to get back to your question, so clinicians on the front line are tasked with thinking about, is this patient in front of me going to get better if I make a decision to hospitalize them or not? And if we as researchers haven't yet provided this kind of information to clinicians on the front line in a consistent, reliable, valid way, just highlights for me that there's a lot more work for us to do to try and make the system better and make pathways of care work better than they do now.

• 17:19Kim Mills?

  What are the most effective interventions at this point? And how does it differ if, say, somebody is having suicidal thoughts and is not hospitalized? How do they get treated versus somebody who is hospitalized and gets a different level of treatment?

• 17:35Speaker 01

  I'll, I'll start with what happens outside the hospital, although there's, there's some blurring here because things that happen outside the hospital, cognitive behavior therapy, for instance, also is delivered inside the hospital. So there's, there, there is certainly some consistency across the two. Outside the hospital, in terms of psychological interventions, our, our strongest effects right now are for psychological treatments like cognitive therapy, cognitive behavior therapy for suicidal behavior. There's a specific manualized intervention from Aaron Beck years ago and follow up by Greg Brown and others at University of Pennsylvania. Really excellent intervention for those at risk for suicide. So it takes a classic cognitive therapy, cognitive behavior therapy and focuses on suicidal behavior risk.

• 18:19Speaker 01

  Dialectical behavior therapy has shown pretty consistently to be a really helpful treatment for those at risk for suicide. And there's some newer suicide focused interventions, one called CAMHS, developed by David Jobs at Catholic University, which is a collaborative approach to suicide risk where the clinician talks with the client, a patient about what are the motivations, the drivers of their suicidal thinking and, and risk for suicidal behavior, and tries to validate those and approach them in a really collaborative way. A really exciting new, newish intervention that's been made available. So there are some suicide focused psychological interventions. I say suicide focused in that they're designed to specifically for people at risk for suicide

• 19:02Speaker 01

  and they talk with the patient, the client about suicide. They don't shy away from it. It's try to understand the motivation, what are you trying to accomplish with efforts in your life? And how can we teach you, how work with you to help you develop skills that alleviate that pain, that teach you alternate ways of monitoring and managing that pain and help you build a life worth living? How do we increase the protective factors and the meaning in your life and the connections in your life? And that's in a nutshell, again, I'm cartooning this a little bit, but this is what those, these treatments are trying to do. And there's evidence that they work, that they, they work for decreasing the risk of suicidal behavior. Those are largely historically developed and tested and implemented outside of hospitals.

• 19:45Speaker 01

  But increasingly, and there's some exciting work right now happening to try and tailor these interventions for use in inpatient settings. So make them very brief so they can be administered during a, let's say, five day inpatient stay and then followed after patients leave the hospital. So you learn some skills in the hospital when you're at this really high risk period and then they get used and developed further when you leave. There's also pharmacological interventions that have shown to be effective, mood stabilizers like lithium for, for people with bipolar disorder that seem to have anti suicidal properties. There's evidence that people who get lithium with bipolar disorder have lower risk of suicidal behavior. Clazoril for people with psychotic illness and so on.

• 20:27Speaker 01

  So there, there do seem to be some medications that work especially well for people at risk for suicide. And I mentioned bipolar disorder, it's a really high risk disorder. 20% of people with bipolar disorder sadly will die by suicide. So it's really important that we, we, we try and develop effective interventions and anti suicidal interventions for people at high risk. And lastly, and moving back to inpatient care, there's some really exciting psychiatric work happening on trying to develop more fast acting treatments for people at risk for suicide. Listeners may have heard about the uses of ketamine as an antidepressant and anti suicidal drug option. There's a lot of work now testing, how can we get it to work for more and more people?

• 21:11Speaker 01

  Doesn't seem to work well for everyone. How durable are the effects of, of ketamine? ECT, electroconvulsive therapy, I know has a controversial history and some people have a concern with the ethics of administering shock to people, but it does seem to be really effective for people with treatment resistant depression. And it does seem to have pretty strong anti suicidal properties. So in extreme cases, when other interventions aren't working, it does seem to be a, an effective option. And perhaps related in terms of brain stimulation, transcranial magnetic stimulation using magnets to try and change the activity of different brain circuits in a really targeted way

• 21:53Speaker 01

  also seems to have pretty good antidepressant and maybe anti suicidal properties. And this is the treatment that's administered a few times a week for a number of weeks outpatient traditionally. And now researchers are experimenting with accelerated versions of TMS, transcranial magnetic stimulation, where you might get many treatments per day in a hospitalization to truly try and make the treatment more compact. So give you more sessions in an accelerated timeline. And that does seem to have.

• 22:24Speaker 01

  Good effects on depression and we're experimenting how can that be used as a fast acting treatment for suicide. For me, it's a really exciting time seeing interventions like these ketamine, ACT, TMS. Psychedelics are also getting increasingly experimented with and bringing these to hospital settings where we have people for just a few days when they're in this really high risk state and testing, can we really turn levers in a targeted way and try and decrease people's risk while we have them safely being treated in the hospital. This is especially important because the absolute highest risk time for dying by suicide is in the weeks after a hospitalization for psychiatric risk, which maybe is a little

• 23:09Speaker 01

  counterintuitive. You think if we get a person into psychiatric care, they're now going to be, you know, they're sort of out of the woods. But statistically speaking, the rate of suicide death skyrockets after discharge from a hospitalization. And I don't think that's because hospital is making people suicidal. I think what's happening is we're doing a good job in the front end. We're finding people at risk. We're getting them into the hospital. We're getting them in patient care, but we haven't yet identified strong enough interventions and we aren't yet doing a good enough job monitoring people when they leave. What we do for suicide, what we do for psychiatric care, for psychological care, looks very different than what we do in heart disease and stroke in other areas of medicine where

• 23:51Speaker 01

  we do really careful monitoring of people and we develop interventions that tailor treatment to the person based on scans that we're doing in a continuous way, I think about heart disease. And we do intensive cardiac rehab after a person leaves the hospital after a heart attack. For suicide, what we do is hospitalize someone and then when they leave, we make a recommendation that they follow up and get outpatient care, see a psychologist, see a social worker, see a psychiatrist. But there's not the same level of follow up that there is for other areas of medicine. So this is something that we're trying to get better at.

• 24:22Kim Mills?

  Let's talk for a moment about technology. I know a lot of your work has focused on the use of technology in suicide prediction and prevention. Tell us more about that work. I mean, what kind of studies have you done and what are you finding?

• 24:35Speaker 01

  Here too, I'm really excited. I think it's, it's a really exciting time in the, our ability to understand, predict and prevent suicide because of the kinds of technologies that are being developed. So I've been working in this area for 25, 30 years. And for all of this time and for many years, I know before, we'd been sort of wringing our hands. Sorry, this is a roundabout answer to your short question. Wringing our hands because there's some challenging aspects of suicide. It's a low base rate behavior. So although it's a leading cause of death, it doesn't happen a lot in time and place. And it seems to be caused by the complex interaction of many different risk factors. We're doing specific studies to try and get better at prediction and prevention, but

• 25:18Speaker 01

  it's from this perspective of we've done this in other areas, can't we do the same thing here using the same kind of logic and data? So we're doing things like using electronic health record data that gets collected on all of us, right? So you, I hopefully on some cadence, go to see our primary care doctor, maybe go see an outpatient therapist, maybe we get inpatient care. And the doctors generate little numeric codes each time they see us and treat us and bill us, indicating what kind of problems, conditions we came in with and what kind of interventions were provided. That all gets, it used to be written down on pencil and paper and put in file folders and slid in a filing cabinet, as you and I may remember. Now all of that's digitized.

• 26:01Speaker 01

  So it's all zeros and ones, you know, on a server somewhere. What we found is we can apply statistical learning to those numbers and extract from them risk factors on the things that we know are important bipolar disorder. Do you have a bipolar disorder diagnosis? Do you have a depression diagnosis? Have you taken antidepressant? Have you said that you've experienced pain? We can extract information from a lot of risk factors, weight them, add them up, make a prediction about whether each patient's going to make a suicide attempt or die by suicide. And we're getting pretty accurate predictions on whether someone's going to make a suicide attempt in the next month, in the next, are they going to die by suicide in the next year? Not perfect by any stretch.

• 26:44Speaker 01

  There's a lot of error in our predictions. We have a lot of false positives. A lot of time the flag goes up saying this person's going to make a suicide attempt and they don't. And that's something we've got to wrestle with and there's a lot of debate in the field about how accurate do we need to be? How should we consider false positives, false negatives and so on? But in the past 10 years, these models have gotten increasingly accurate and I think increasingly actionable. So that's a big focus of our work now is on trying to use data that we already have in hand to get better at identifying which patients in our healthcare system are at high risk. And so we should attend more to, to decrease their likelihood of dying by suicide. Another part of our work then picks up from there and says, now that we know someone's

• 27:27Speaker 01

  at risk in the next year, say you get a person who their profile suggests they've got, let's say a 40% chance of making a suicide attempt in the next year, but we don't know when. So we're doing, in another line of work, we're following people with, by putting apps with their permission on their smartphone and we're passively monitoring signals from their phone or from a wrist worn device. And we're getting, you know, simple stuff. We're sending people surveys, asking them, how are you doing today? What's your mood like? Are you alone? Are you with other people? Are you having any thoughts of suicide? And we're getting simple stuff about sleep and steps and GPS. Are you in parks or are you in church or are you in liquor stores? Are you connected with other people?

• 28:12Speaker 01

  Are you calling and texting them? Are they calling and texting you? And we're getting some exciting findings. We just, we published a paper just recently in one of the APA journals, Journal of Psychopathology and Clinical Science, showing that we can, we can identify in some of our best models about 87% of suicide attempts and hospitalizations to prevent a suicide attempt a week before they happen, just from the survey data. This isn't yet fully in all of the other sources of data that we have, step count and sleep and voice data samples we're getting and so on. And in a separate line of work, we're developing and testing digital interventions that can be deployed to people right in time. So they're called just in time adaptive interventions.

• 28:54Speaker 01

  So it's Friday at 6:00 PM. I see my clinician every Tuesday morning and Friday at 6:00 PM, my, my risk starts increasing. What do I do? How do I manage? How do I, do I wait until I see my clinician on Tuesday? Well, through our model, we're finding when people are at risk and we're deploying different kinds of interventions and we're doing little experiments to see what's the right intervention for the right level of risk for this person to try and bring care to people when they need it, rather than relying only on our traditional psychotherapy model, which is come in, come in to a brick and mortar clinic or log into, you know, Zoom these days and see your clinician at, once a week at a predetermined time.

• 29:38Speaker 01

  I think this is, this is not a sufficient model to treat the ebb and flow of suicidal thoughts or alcohol use urges or drug urges or urges to binge and purge and so on. A lot of the behaviors that we're, people struggle with don't follow the timeline of our predetermined psychotherapy sessions. So we're using new technology to try and respond to that and wrap treatment around the person rather than waiting for the person to come to us.

• 30:02Kim Mills?

  I want to ask about the role of chatbots in this situation. I mean, are they for good or for ill in this case?

• 30:10Speaker 01

  Yeah, this is a great question and it's one that people are talking a lot about now and there's a lot of science coming out about this. I think of chatbots the same way I think about the internet and the telephone and, you know, lots of new technology, dating back to, you know, the sharp object. Is it used to, you know, cure disease and perform certain life saving surgeries or is it used to, you know, attack someone else? These are implements. These are tools and it's up to us as humans to determine how we're going to use them for good or for evil and they can be used in any direction we want. I'm optimistic about the possibilities of using chatbots, of using large language models,

• 30:52Speaker 01

  as you can tell by my responses, as using technology to try and, to try and help people. I talked about hand wringing earlier that we've been doing for decades. A lot of what many of us have been lamenting for the past few decades is there's a lot of unmet need in terms of psychological illness, psychiatric illness.

• 31:10Speaker 01

  A lot of people struggle with depression and anxiety and suicidal thoughts. And the average length of time that someone goes struggling with an illness, a mental illness, before they get treatment is around eight years or so, eight to 10 years. There are evidence-based treatments available. Most people don't have access to them. And there's, there's great inequities in access to care based on how much, what your income is, where you live, what part of the country or the world you live in. There might not be a psychologist or a psychiatrist for, for hundreds of miles. If only there was some way of democratizing treatment and making evidence-based psychological interventions available to everybody when they needed them for very low cost or for free.

• 31:55Speaker 01

  And I think large language models, chatbots, provide the opportunity to do that. Now, it's not a given. It's, you know, we've got to think carefully about this and be thoughtful and, and design them and program them and guardrail them in a way that leads them to provide helpful interactions. But I think it's for us to figure out how to do that and for scientists and clinicians and healthcare providers and folks in the industry to work together to try and use these tools to help improve human health and functioning. But there's, you know, there's errors that can be made along, along the way. And there's, there's wrong ways of doing this that can certainly lead to harm, as there are for any, any field or any new tool.

• 32:35Kim Mills?

  I want to close out by asking for some practical advice for our listeners. What should parents, friends, relatives do if they know someone or they think someone they know is at risk of suicide? Should they talk to the people about it? I mean, how, how can you move past the fear of saying the wrong thing, starting the conversation and being helpful?

• 32:57Speaker 01

  Yeah. Great question. I'm glad you asked it. It's probably the most common question I get when I talk about suicide and, you know, to, to, to public groups is, what should I do? And isn't there harm in asking? And this has been a fear for, forever, since I can remember. If I ask someone if the rat was for suicide, maybe that will give them the idea and it will be my fault. I will have made things worse. And at this point, there have been many experiments on this exact question and the results are very consistent. It is not harmful to ask people about suicide. It does not give people the idea to ask people about suicide. And the same way it doesn't ask people about homicide. Are you thinking about killing someone? No, but now that you mentioned it, now I'm going to go kill. It just doesn't work that way. Humans don't operate that way.

• 33:41Speaker 01

  And the same is true for suicide. And the first landmark study on this was by Maddy Gould at Columbia in 2005. And it was published in the journal JAMA, for those who are interested. And she did an experiment and asked some kids about suicide and not the others, and then followed them up. And people who were asked about suicide were not more distressed, were not more likely to think about suicide, were not more likely to engage in suicidal behavior. And this has been replicated over and over again. It is safe to ask people about suicide. If you think someone might be thinking about suicide, you should absolutely ask them. Easier said than done. People are almost always nervous to ask a question. I've been, I, I study suicide for a living. I've been doing it for 30 years.

• 34:25Speaker 01

  I still get nervous, admittedly, asking friends and family if I think they're at risk, asking the question for fear of how is someone going to respond? Are they going to get angry? Or is it going to damage our relationship in some way? But I've also learned, more than anything over the past number of years, better to ask the question and have that conversation than to not. And then to wonder, should I have asked? Should I have approached the subject with them? I've found over and over and over again, people, in my experience, are glad to have been asked. It shows that you care. It, it opens up that channel of communication. So even if they say, no, you shouldn't ask me that, they now know you're someone they can go to and talk. And it usually helps the relationship much more than it harms it. So what I always advise people to do is I use the acronym AIR.

• 35:09Speaker 01

  Give somebody AIR, A-I-R. Ask the question and then show interest in the response, whatever it is, and then refer the person. Don't try and do this all on your own. So asking the question, I usually ask it in a way of not just, are you going to kill yourself? I try and lead up to it. And I also don't ask it in a way that's leading a person to say no. I've seen a lot of people say, you're not thinking about suicide, are you? That then requires the person, it's, it's leading the witness, your honor. So I would ask, hey, it sounds like you're really down, whatever, whatever situation is, whatever information they're giving you. Have things been so bad that you've thought about ending your life or dying? Have things been so tough, so difficult that you've thought about suicide? And pause and give them space to, to ask.

• 35:54Speaker 01

  I wouldn't pull for, don't pull for no, as much as you might want to hear no. Ask in a very curious, the way I was taught, calm, dispassionate demeanor. Have things been so tough that you've been thinking about ending your life or suicide? And then pause and let them respond. And then demonstrate interest. Not, phew, I'm glad you weren't, or, okay, then you turn around and walk away. Wow, sounds like that's tough for you. Or, okay, I'm glad I asked, please let me know. Demonstrate interest in the person and follow up. And again, signal that it's okay to talk with them about this and you're willing to have that conversation. Just as importantly, refer. Don't try and manage everything on your own. Don't try and do it all on your own.

• 36:35Speaker 01

  Refer the person to a clinician, if they have a clinician, one of their, if it's a child, their parent, their coach, their, their peers, their siblings. Most importantly, 988, bring them to the emergency department, follow up and encourage them to, if they don't have a clinician, you can help them find one. There are therapist finders online. I'm sure APA has, has one. abct.org has one as well. You can go on and put in your, your zip code and find a clinician near you who does evidence-based treatment. So there are ways of finding help online if you, if you don't have it readily available. But again, don't feel the need to do it all on your own. This is something we hear from, from people, especially common in young people anecdotally. Yes, I'm thinking about suicide.

• 37:19Speaker 01

  Please don't tell anyone. Promise me you'll never tell anyone. I would not make that, that promise. I have not made that promise. I would say, no, I care about you. I want you to be alive. This is why I asked. And so even if it means losing you as a friend, but I keep you alive, I'm going to go talk with someone about this. I'm going to try and get you help.

• 37:37Kim Mills?

  Well, Dr. Knack, I think that's very good advice. And I want to thank you for all the great information you've given us today. This is a very important topic.

• 37:45Speaker 01

  Great. Well, thank you again for having me on and thanks for covering it. And really appreciate all the work you all do.

• 37:50Kim Mills?

  You can find previous episodes of Speaking of Psychology on our website at speakingofpsychology.org or on Apple, Spotify, YouTube, or wherever you get your podcasts. If you like what you've heard, please subscribe and leave us a review. If you have comments or ideas for future podcasts, you can email us at [email protected]. Speaking of Psychology is produced by Lee Weinerman. Thank you for listening. For the American Psychological Association, I'm Kim Mills.