Suicide Prevention with Dr. Igor Galynker

You should trust your feelings absolutely, and you should not suppress them, which kind of puts us clinicians in a bind because we're trained to suppress the feeling. It's called professionalism and behaving a certain way. But what we need to do is that we need to feel, have a feeling, identify it, and then manage it, which is a very different story from suppressing it.

Hello, I'm Dr. Farah White.

And I'm Dr. Grant Brenner.

We're psychiatrists and therapists in private practice in New York. We started this podcast in 2019 to draw attention to a phenomenon called the Doorknob comment. Doorknob comments are important things we all say from time to time, just as we're leaving the office, sometimes literally hand on the doorknob.

Doorknob comments happen not only during therapy, but also in everyday life. The point is that sometimes we aren't sure how to express the deeply meaningful things we're feeling, thinking, and experiencing. Maybe we're afraid to bring certain things out into the open or are on the fence about wanting to discuss them. Sometimes we know we've got something we're unsure about sharing and are keeping it to ourselves. And sometimes we surprise ourselves by what comes out. Welcome to the Doorknob Comments podcast. I'm Grant Brenner. I'm here with my co host, Dr. Farrah White, and we are very pleased to have Today our guest, Dr. Igor Glinker. Dr. Ginker is an American psychiatrist, clinician, and researcher known for his work in bipolar disorder, suicide prevention, and the role of family dynamics in psychiatric illness. He is currently the Associate Chairman for Research in the Department of Psychiatry at Mount Sinai Beth Israel, and serves as the founder and director of the Family center for Bipolar Disorder, as well as the Mount Sinai Suicide Research and Prevention Laboratory. He is also a professor of psychiatry at the ICAN School of Medicine at Mount Sinai in New York City. Welcome, Dr. Ginker.

Thank you for having me. Pleasure to be here.

So today we're going to be talking about suicide prediction, prevention, and everything to do with that, which is an area of specialization.

Yes.

And I know that you've been, you know, you've had quite an illustrious career, did some teaching of residents. So we actually know each other from when I was in training. I think that the audience would want to hear a little bit how you came to this topic as, you know, your main research and why you decided to dedicate yourself to this.

Well, that's a good place to start. So I'll be happy to tell you that, because I actually Thought about it quite a bit retrospectively. And there are actually two reasons why I became a suicide prevention researcher after being a bipolar researcher for a while, meaning research in bipolar disorders. There's a conscious reason and subconscious reason. So the conscious reason was that about. In 2007, then the medical director of the American foundation for Suicide Prevention, Paula Clayton, gave a talk at Beth Israel about suicide prevention and the organization in. And there was a lot of serotonin impulsivity, brain imaging, genetics in that talk. And there was nothing said about suicidal mental state. And after the talk I gave ask our question is that, well, this is all well and good, but do you actually know what's in a person's mind the day they kill themselves, which is different from the day before or in the appointment, last appointment, when you see them as a clinician from the appointment before? And she said, no, we don't. And at that point I realized that we have a giant gap in our knowledge in suicide prevention. And that is description of suicidal mental state, that we were focusing actually on something entirely different. So that was a conscious reason. The subconscious reason was that about 10 years prior to that, I lost a patient to suicide. And that was in my second year as an attending at Beth Israel. And the patient was referred to me, to my chairman at the time, Dr. Winston, who was grizzled, a very experienced clinician who didn't want to deal with the case. Okay. And actually sent to me, as I understand right now. So he was a 53 year old gay man who ended up with the following story. He had a partner who was an, I think North Korean defector that he lived with for 20 years. The partner was working in a restaurant as a busboy and they lived together happily for 20 years. And then the partner got actually liver cancer and the. My patient took him home and then he died there at home in my patient's arms, so to speak. And then when he started making funeral arrangements, his wife, the partner's wife and three children, all of them teenagers, okay. Showed up at the funeral. So it turns out that the partner led a double life, okay. Had a second family. And the patient didn't know anything and absolutely shattered his world. Okay? And the fairy tale, and I tried very hard to reframe it, to open some doors for attempted future, unsuccessfully. And at one point he said, well, I think I'm going to try to do what you're telling me. And then so I'm going to go to Thailand and see if I find another Asian men, you know, younger model and see what happens? And so he did. And it felt a bit strange to me at the time, but he did left. And then a day later, I got a call from the local precinct that he killed himself. He planned it actually recently, but carefully. And then a week later, I got a letter from him sent before he died and a gift, actually a package, and saying, doc, doctor, you did everything you could. I mean, don't blame yourself. That's just kind of how it needs. It needed to be. And so obviously it affected me. And it took me a while to process that, but I didn't realize at the time how deeply the story actually touched me. And then when the second thing happened, I realized that, you know, there's a unique opportunity, meaning which, by the way, rarely happens in medicine, is that you have a missed syndrome, which is suicidal mental state that nobody knows about, that's a key to suicide prevention that is probably staring everybody in the face and hitherto undescribed. And so at that point, I quit bipolar research and started dealing with suicide prevention, describing suicidal mental state. So that was now 16 years ago.

It's such a tragic story and something a lot of us will inevitably go through in our career.

Yes, well, it also depends. It depends of what do what you do and what kind of patients you see. Some people may not have a patient who dies by suicide if they deal with low risk population, and some doctors would have several. I mean, I had actually three people who died by suicide over a period of about 35 years now, because I work with very acute, acute people and what they all had in common. And nine people died by suicide after they left me within my treatment for about. In about a month. Within a month. And what all of them had in common is that everyone at the time denied suicidal ideation. Otherwise I would have probably hospitalized them at a time or intensified the treatment. But that informed the framework that suicidal ideation will not be part of the syndrome. It may or may not be there, but it's not critical and it's misleading. And in later research, what we discovered is that the syndrome as we described it, and, you know, I can talk about it more if you would like me to, let's say, has a certain predictive validity for suicidal behavior, let's say 90% within a month. And if you add suicidal ideation to it, it changes by 1% to 91%.

So that factor doesn't make much of a difference.

It has about as much predictive validity as severe anxiety with strange, strange sensations you never felt before. About the same which people, by the way, would tell you much more readily about than this. You said radiation quite often when you.

When you mentioned that unconscious thought, you connected it later. You mentioned in the last session that you saw him, that there was something strange about it. Do you have a sense of what that was, looking back? Because I know that's one of the things in the suicide literature we talk about is that feeling that the therapist or the psychiatrist sometimes has. And it can be hard to kind of register.

Yes, we actually looked into this. So the framework for our research was, is that we psychiatrists. And so I at the time had a feeling that we didn't know what it was, that we couldn't characterize that the patient had suicidal ideation in their mind. And we didn't know what it was and then we didn't communicate. What we did is that we researched both the suicidal state of mind as well as the clinician's emotional response and then put it together. It's actually, the feeling is now pretty well defined. There's several feelings that you would have, you can identify. One is just your own feeling of distress, just plain distress. And it is something that. Which is out of the ordinary for the situation. I mean, that you have a discomfort and distress. The second feeling is what we called anxious over involvement. And it's a paradoxical feeling, meaning it's combination of hope and anxiety. If you are hopeful for the patient and you think that the patient is going to be fine, that should calm you down. Okay. And yet at the same time, you feel very stressed and you overextend yourself to the patient and start doing things that you typically don't do, such as answering phone calls and more frequently, calling them and checking how they're doing. So this is the second emotion. This is a sign that the risk is high as well as distress.

You're on this paradoxical feeling, like a part of you is hopeful, but a part of you is not. Is not buying it.

Absolutely. And the other one is another paradoxical feeling which we call collusion, abandonment, or distancing. And it's a combination of hopelessness and calm. The first one was hope and distress, and the second one is hopelessness and calm. Meaning, you know, okay, you know that the. Not only that the patient may kill himself, and you may also even think that, well, if I was in his shoes, I would kill myself too. Or maybe, I mean, maybe that is the way to go.

That's the collusion.

Yes. At the same time, you don't feel the thing. Okay. You just wanna actually Distance yourself from the situation.

So maybe something like a dissociative response.

So that's the third feeling. And, and when I do rounds, usually with what I do, research assistants and previously with residents, we actually examine our feelings when we talk to suicidal patients. And this is part of the rounds that we have, and I'll call it counter transference rounds, when people need to first learn to separate their feelings from their thoughts, which is not an easy thing, by the way, for a lot of people. But this is something that we train people in. You should trust your feelings absolutely and you should not suppress them. Which kind of puts us clinicians in a bind because we're trained to suppress the feeling. It's called professionalism and behaving a certain way. But what we need to do is that we need to feel, have a feeling, identify it, and then manage it, which is a very different story from suppressing it. And that gives you about 50% of the information in terms of making your clinical decisions and determination of what to do with suicidal patient that you should not ignore.

I think that's really good advice to anyone who works with sort of high risk population. Once people have identified that there's something a little bit off, what they're feeling, a shift counter transferentially, what types of steps do you recommend people take and how has your research sort of informed that? Because I think we feel a lot of things when we're working closely with patients and some things we can certainly act on and some, you're right, do need to be.

Yes. So here we come actually to two key concepts in, in our research and the results. One is the what suicide crisis syndrome, which is acute suicidal mental state. And the other one is narrative crisis model of suicide, which is a progression of suicidal mental state, which in American terms will be described as from low risk to imminent risk. Okay. In European terms, it will be described as intensifying mental state. Okay.

To so on that latter point, the narrative, right, so the person is. Is altering their sort of autobiographical story of their own future, where suicide becomes more and more part of their future. And I've certainly seen this in my clinical practice where people may have like an idea that maybe in. In some significant period of time, in the future, could be many years, they have an idea that that's how their life ends and that that narrative gets more and more elaborated, they spend more time on it. Is that the kind of thing that you're talking about has something to do with their story of themselves?

Not, not quite. Although that could be one of those Narratives. The narrative that we're talking about, which is the third stage of the model, a suicidal narrative. And suicide crisis syndrome is the fourth and final stage, most acute stage. It's a narrative that has no future, okay? It's before we actually the suicide in the future that a narrative has no future, no acceptable future, okay? And you ask people said, do you see a future? The answer, the answer is no. I mean, it's like flat out they cannot tell it. And this theory comes from a life narrative theory, which is a psychological theory of I guess of our mental state that we all have our own narrative identity. Narrative identity theory, which has the beginning, the course, the present and the future. And that narrative identity changes, okay, and becomes distorts into something which is very specifical, also has kind of several components to it. Starting from an achievable goal, a failure to achieve that goal. That means failure to be happy, self degradation, inability to connect with people, being rejected, isolating and then seeing no future, okay? Be feeling like cornered in the dead end. That's the story. The actually suicide being part of the future, okay. As one of the doors and a person can open, can give them comfort, okay? But. But I seen more. Is actually no future. It's that which will lead to the desperation of the suicide crisis syndrome, which is the final stage. And that's actually the closest way to understand it. The simplest way to understand it for a clinician is it's a state of psychotic panic. And it has a combination of affective disturbance, agitation and also loss of thought control. That's the psychotic component. And at that point, when a person is like that, you cannot change their narrative. You can't, they can't hear you.

Is it like a delusional state?

It's a delusional state. It's more like it's thought processing state, okay. As well as delusional state. It's actually literally they can process what you're saying. And what is critical is that that means that when people are in this stage, psychotherapy is ineffective because they can't hear you. They can process it. So I might as well go through the criteria of the syndrome, I think.

Which I think let's sort of, let's go top level. So you've. You've developed a model of suicide crisis syndrome. And we'll go through what that is. And that's a real contribution to the field. The way, the way I think about it, and it's probably wrong, but for the purposes of communication in general medicine, not in psychiatry, we have things like A heart attack. We have a model for that. And it's kind of similar. Like people might have years of worsening plaque disease in their arteries. They might have a little bit of pain here and there, they might have an abnormal ekg, they might be taking medication for high cholesterol. But there comes a time when something acute happens and it's biological and the blood vessels close up in the heart or they spasm. The blood supply is cut off. The, there's damage to the heart tissue. And we call that a myocardial infarction or heart attack. In, in a, in a way, I, you know, like I said, it's probably wrong, but I, I think of this acute phase as being something like a brain attack and it should have a medical framework around. We ideally would have a way to treat this acutely. There are some biological treatments that may help. I'm, I'm a, a psychiatrist who offers transcranial magnetic stimulation, which is not indicated for acute suicide right now. But certainly when we treat patients, their suicidality often dissipates within a day or two. And there's some other treatments that have been shown to do that as well, like medications. So I wanted to just frame that idea of suicide crisis syndrome as like a medical event.

Well, it's a good analogy. I use a similar analogy, which is actually not myocardial function, but chf, congestive heart failure, which is less probably known the most than, than heart attack. And the reason I use CHF is that heart attack is not reversible. You had a heart attack and that's. That CHF is reversible, as is suicidal state when you treat it, I mean, it resolves. And when somebody is in chf, you give them diuretics, it resolves, they come back, let's say if, if, if it's not particularly severe. So yes, that's, that's an evolution of the, of the stage from there are certain things that predispose people to developing suicidal state under stress lifetime. That sets long term, what we called long term vulnerabilities. And there are many of them and them is, increases your risk lifetime two, three fold. And the most well known ones actually what people think about is impulsivity, past suicidal behavior, mental illness. But actually probably the most critical one that people don't think about is perfectionism. Perfectionism, then pessimism, fearlessness. Okay, fearlessness is a critical, it's actually a trait. It's not a quiet capability. It's a trait. And that's why military and policemen, among other things, kill themselves and the psychopathology that they have actually precedes their combat exposure and violent exposure. It's not the result of it.

And you said fearlessness.

Fearlessness. And the only protective factor, by the way, which is that that works like is moral and religious objections to suicide. Family, contrary to popular belief, family does not work. I mean, when people are in that state, I mean, they unfortunately jump out of windows with their children, okay? As it happened, you know, at Mount Sinai last year. The. So that's long term, by the way. If there is no stress, okay? And stress comes in the particular varieties, these people are not, not at risk. And just like, you know, when a person, let's say, who has unhealthy diet and a young person is not at risk now, but lifetime there may be, it's a similar situation. And then, you know, stressful life events come, which come like in five or six varieties really. And that is final romantic rejection, which is associated with suicide within 24, 48 hours. So if a person made it for two months, I mean, they, they're okay. They're on the other side. Catastrophic financial failure, like blow to, severe blow to ego identity has happened to my patient, all right? Because his whole life was shattered and identity was shattered. Bullying, onset of life threatening medical illness, particularly in the elderly, and the relentless painful mental illness, okay? For a long time, which is actually the hard, one of the hardest ones to treat. And so when that happens, I mean, to people who have long term vulnerability, vulnerability, they may develop suicidal narrative. And that is the stage that requires intervention and a fairly quick intervention. And at that state, before people develop suicide crisis syndrome, they're actually amenable to therapy. They can hear you because they're not in the psychotic state.

There's a window of opportunity that's fairly.

Narrow and it would be like a crisis intervention situation. So. And suicide crisis syndrome is they can't hear you and that needs to be treated medically. Okay? And usually it takes 24, 48 hours. It's actually sometimes very quickly, okay. And then they can hear you. So that intervention can be administered in the office or even in an emergency room. Definitely in cpap. Yeah. So suicidal narrative is treatable. And the important part about this, what you know, as, as Grant, you mentioned, is what clinicians think about and what they worry about and also the relatives, is that people actually talk about it, okay? People who are suicidal, they're not going to tell you that they're suicidal. And if they tell you that they're suicidal, if this happens, I'm going to Kill myself. It might mean nothing. But what they do talk about is about this suicidal narrative, okay? They talk about what happened. They talk that they had this goal that they want doctors and, you know, that they failed the exam and their family, immigrant family that was supposed to were paying for them, taking care of them. They cannot show up their face there. They can't live. They're going to tell you about this and, you know, being a nurse is not going to do. They're going to tell you about that and that they're ashamed and they're miserable. That is the components of suicidal narrative that you need to listen to, which are more telling about actually suicidal mind than suicidal ideation. That's the important.

I wonder if you could talk about. So at that point, when a person has that narrative and it's sort of coming together, what do the interventions there look like as opposed to once they've progressed to the sort of crisis syndrome?

Well, our hyp, we hypothesized that suicide crisis syndrome, and we have data for that. By the way. The suicide crisis syndrome is a matter of days maximum. It resolves within three days, typically with treatment, whether inpatient or outpatient. So assume that onset is three days. The narrative. Actually, people are discharged from the hospital with a narrative. They don't just. And they're not discharged from the hospital with the crisis, crisis is resolved. And so if the crisis is resolved, then your safety plan, for instance, would work because people can think, okay, but if it's not resolved, it's not going to work. So it lasts weeks, let's say several weeks typically. And that medication wise, just to make it simple, that actually is a window of opportunity for you to treat somebody with antidepressants if they're depressed because there is enough time, okay, for antidepressant to take effect. The psychotherapeutically, however, the, the best treat, the most dangerous is perception of no future, because that's what goes into suicide crisis syndrome, which is part of entrapment. Part of it is entrapment and being stuck.

Entrapment. Entrapment meaning, excuse me, like the person feels this terrible, terrible psychological, emotional pain and they feel trapped that there's no good options. They see no future.

So let's, let's separate. Let's separate that. Okay? And so you said the narrative is a cognitive state. Okay? It's actually thinking, just as Grant, you described it, when in your situation, the suicide becomes an option at the end, but it's a thought. Suicide crisis syndrome is a mental state. It's like it's longer than the panic attack. It's very distinct from a panic attack. People who have panic attacks know the difference and that needs to be. That needs to be treated. So the narrative, when people can hear you, you restructure, try to restructure the narrative to life narrative, whatever it can be, whatever is the most acute stage, let's say perception of no future is most acute stage. You try to create alternative future that people at least can accept or see or fathom. That's the most critical thing. So this is not entrapment. This is just lack of future expectancies. Entrapment is this. You described actually suicide crisis syndrome and how it feels. Entrapment. The better term for this is forensic hopelessness. It's also contradictory term. It's like one of my patients who by the way was suicidal, but never told me, and told me only later, like weeks later or actually months later, said like that. It's like you're in a department store. Everybody's like around. You seem to be doing something, and then lights go out. You all alone and you want to get out, and all the doors are locked. So he is a lawyer and that was his state. That's the state. A desperate need to get out of that situation. And all the doors are locked. It's a suicide entrapment. It's actually forensic hopelessness is not a thought, it's an urge. Suicide crisis syndrome. It's an effective feeling. It's an urge. It's not a thought, it's not rational.

So what is that word? What kind of hopelessness?

Frantic. Hopelessness.

Frantic, got it.

And restlessness. So that's the first criterion, the most important criterion. Then the second criterion that you alluded to is loss of affective disturbance, which is emotional pain. Severe anxiety with strange sensations that I mentioned. Acute and hedonia. People lose ability to experience pleasure. And also, also, also depressive turmoil. A rapid change in emotions from negative to positive. Okay. You can interpret it to yourself as like somebody is feeling absolutely terrible and let's say suicidal. And then they make an effort, try to establish something as a possible future. Then temporarily they move to perks up, okay? And then go back into the. Into the rabbit hole. That's kind of up and down, up and down, by the way, the way to ask about it, since we are now talking suicide crisis syndrome, it's like really important to interview people correctly about it. So the first question is like somebody comes to the office or emergency room with a problem, whatever the problem is, and we listen to the problem. And, and the question is now this problem that you have that brings you to my office today, where you're talking about me today, by the way, if you're a lay person, not psychiatrist, okay, are there new options? Do you see a way out? I mean, that's literally very simple question. And if the answer is no, the first criteria is met, then the second question is now this problem that, that you just told me about that has no exit, is it painful to you? I mean, or does it make you panic? And if the answer is yes, it's like I'm in terrible emotional pain. You clarified that, that the second criteria is met. The third criterion is loss of cognitive control. Criteria B2, which is. Has several components. The most important one is ruminative flooding, meaning that you flooded with negative thoughts, ruminations that feel like a rabbit hole to you that you go into and you cannot get out.

Almost like an OCD experience.

Yeah, you can't get out. You try, can and try to climb out. You can't. And these efforts give you headache and head pressure. And some people feel that the head can explode. That's really important somatic component of that. And the way to ask about it is that do you feel that you can control your thoughts or thoughts are controlling you. Okay. And do you have headaches? Okay. Literally like that Is anything you can change the way you think?

You said that's a somatic symptom, meaning the emotion is not expressed in words, but the body is telling us.

Right. And then the criteria B3 and is over arousal, which is insomnia, agitation, irritability and hyper vigilance, which is being kind of hyper attuned to. To. To stimuli around you, whatever they may be. And people can't sleep. Most suicides happen at night. And the way to ask about it is that you know this problem, that it gives you headaches, that you can stop thinking about it. Can you sleep? Okay. And they tell, you know, it comes at night when I'm alone and I can't. And finally the last one is the acute social withdrawal for people who are normally social. And the way to ask about that is that. Does anybody know about this? Okay. Have you told anybody about what we're just talking about? And the reason, by the way, there is a criterion A and four criteria B is that in all our studies, criterion A is the weightiest. Okay. It has about 50% of the weight.

That's the. Do you see a future? No.

No. Do you? This is still back to narrative and thought. I see it. It is. Do you see an option out of your trap. Can you, can you get out? Is there a way to get up?

Yeah.

In adults in adolescence, and this has been presented but not published yet, the weight is reserved. It's social isolation, okay, that becomes more important because social connectedness is so critical for the adolescents in. And the, let's say forensic hopelessness is less important, but rejection. Social isolation is in adolescence.

So what might family members observe? This is kind of how clinicians can operationalize suicide crisis syndrome in a kind of a DSM diagnostic manual style. What do people who aren't trained observe? And we were talking about this sort of idea or myth that some people can seem fine, right? You hear those stories. He seemed fine. He had everything going for him. What do people look for who aren't trained?

First is they need people look for is the. Probably the components of the narrative. Let me give you probably the best, not the best example, the most concerning example. People are very concerned about, let's say children and adolescents. The suicide rate went up and I actually had to give talks in schools about this. And they say, well, totally normal, everything was okay. No, it's not okay. There are only two kinds of people really of kids who attempt suicide, like die by suicide. The first is somebody with relentless mental illness, which started pretty early on when a person was like four and has been the treatment for a long time. And nothing seems to be working. And whatever medications they may be getting is not helping and be making them worse. And because they're different, they're being bullied. Okay? That's the one kind. And the second kind is a perfectionist, overachieving perfectionist that is trying to do everything possible to be a fine tuned sports car that his parents want him to be, regardless of what they're saying. Okay? And that's the second person that. And then B plus okay, could be the stressful life event, okay? Because that means that he is not going to get into Harvard. And that's the only thing that is gonna make him happy or his family happy because everybody went to Harvard.

So it sounds like there's a real narcissistic vulnerability. The person's sense of self and their sense of the world collapses all of a sudden when they face some kind of failure or their idea of how the world is supposed to look is all of a sudden violated. Almost like a stool with only one leg.

Yeah, the stool analogy is a great analogy and I use it a lot in psychotherapy. It's very concrete. But hell is helpful. So, you know, you can't Sit on the stool with one leg, because if that leg breaks, I mean you collapse just like as you described. And there is a theory, which I forgot what it's called, that the most important things in life, love, work, play, and you can add spirituality to it. I forgot the name. So these are the four legs of the stool that the person needs to have, which need to be reasonably balanced. It's not like 25, 25, 25, that does not work, but you need to have four. And if you ask me, I would probably say it should be like 35, 35 or 30, 30, 20, 20, depending of where you're at. But then one, if one legs of the stool breaks, okay. The other three, two actually have to keep you going. And so when people maladaptive way of actually coping with stress, let's say at work, is to drop everything and focus more and more on work and work more and more harder and harder. And that's the exact worst strategy because you abandon the other three legs and then it doesn't work or something backfires and that's catastrophic blow to ego identity. And the adaptive way is actually rely on the other three legs when that happens. Meaning talk to your love, talk to your friends, I mean, go to temple, whatever, whatever works for you, Meditate.

Right. That's correlated with resilience.

Yeah, I do think that in some ways, and maybe we're deviating from this, but when parenting, you know, becomes so. I think it's intensified in a lot of ways, particularly with this generation. And there are lots of different thoughts and theories about how to do it best. But it seems like today society rewards people who are hyper specialized, that we have to develop into some sort of like an Olympic athlete or a musical prodigy or something like that. And it is hard if you want.

To go to a good college.

Right, right, right. It is hard to really explain to people that a healthy, well adjusted childhood does not include really excelling in, in those specific ways.

Yes, I completely agree. And it's a, it's very difficult to undo. I gave, I gave a talk actually in one of the private schools, there was a suicide there. And so I actually gave two talks. I gave just, I gave identical talks, by the way, near identical. I gave it two times. The first time to the teachers at 4 o' clock and the second time to the parents at 6 o'. Clock. And you know, people listen, people understood and teacher said there's nothing we can do because there's so much pressure from the parents, I mean for their kids to succeed. And you Know, if they get one, one, you know, question wrong, I mean, the parent is going to be on top of me. We can't stop. We absolutely can't stop because we're responding to pressure from the parents. And then the parents said, we can't stop because we're getting constant email from the school. Okay. And if my kid, you know, looks the other way, I mean, he needs occupational therapy and ADHD assessment, and if not, because the school wants to get the GPA high, they're going to expel my kids from the school. It's not going to be. So it's a tough, tough thing. Undo.

You know, in a way, I think that's partially a function of kind of a corporate mentality. A lot of these schools, it's almost like hr and everyone is like, so apprehensive about making a mistake. The person who suffers is the kid.

Yes. So I could not agree. Agree more. And unfortunately, I have to say that we, meaning mental health professionals, are playing a significant part in this because when parents come to us and say, you know, I think my, my son may have learning disability or ADHD because he's not getting straight A's, so he needs neuropsychological testing. And of course, neuropsychological testing is going to show something which is not up to par with something else. Okay. And that will require cognitive remediation and then eventually will require stimulus which would generate anxiety and that would require SSRIs. And we're off to the races when somebody is on three medications under pressure at age 15, and it's not a good situation.

Well, certainly there's a whole industry in major urban centers like New York where you essentially pay a lot of money to get the neuropsych testing done, and it's targeted for academics. And I think the impression that the kid gets is that if they're not performing at this high level, they have no value as a human being. And it's, it's just. I mean, it's. That's a topic for a whole thing. And I think there's all kinds of trauma related to this. I think a lot of the symptoms of the suicide crisis syndrome and the lead up to it that you're describing seem to overlap with things like PTSD in a lot of ways. I know there's a lot of trauma related to suicide completion and attempts.

I have to actually address the overlap because this is a critical issue in terms of including suicide crisis syndrome into dsm, which we, you know, working on. And we submitted the application and we're going to resubmit it.

You've got. You've got my vote.

And. Well, discriminant validity. Okay. Which is the fact that actually SES is different from other disorders, including ptsd. Okay. And depression is critical. And we actually just wrote two papers on two different samples that it is different. Okay. And transdiagnostic.

Yeah, there's overlap in the dsm. It's. The term is polythetic, meaning they're categories that overlap. And there's a lot of redundancy. I think we need a better system that's based on biology in the brain. I did want to ask briefly if there is any sort of. What is the neuroscience here, which is, you know, we're just beginning to really understand neuroscience, I think.

But the. We published a paper, suicide crisis syndrome, what to test next. And there, phenomenologically, there are four neurotransmitter systems involved. The first one is arousal, and it is gaba, and that's why benzodiazepines work. The second one is loss of cognitive control, which is dopamine. That's why antipsychotics work. The third one is emotional pain. Okay. That's why opiates work, including ketamine, because it's an opiate. That's why it works. And the last one, possibly oxytocin. Okay. Which is social connectedness, but I haven't seen yet that it's available, by the way, as a pitocin to induce contractions in labor. And some people use it clinically, but I haven't seen that being effective. But the first three are.

Yeah, there's some studies of intranasal oxytocin and lithium. Reduces suicidality and some other drugs. Like I said, I've seen patients with tms, their suicide, even people with chronic suicide from their preteens, has disappeared in a week, which we don't quite know what's happening, though I think of that more from the level of brain networks. So if you see these sudden switches in mental state, it's likely, you know, that there's switches in the network, certain parts of executive function coming offline. For example, if you can no longer talk to the person and connect with them. So we're coming into the last few minutes. Farah, is there any. Do you have any burning question or topic? I thought it was great to bring up the role of the family and the academic environment.

I mean, these are our huge contributions. And it's a really exciting time, I think, to be a psychiatrist as a result. Right. We're learning that there's so much more that we can do. And the field, you know, is making great strides thanks to people like you guys. But I am wondering where people can find out more about the work that you're doing, how they could either follow along or. I know you have the Bipolar Family center, so.

Well, if people kind of just Google my name, what's going to come up is Mount Sinai Suicide Research Prevention Lab, then Galanka Family center for Bipolar Disorder, and now Family center for Suicide Prevention, which we just opened recently, which uses this system. Okay. We actually stage you settle, process and treat accordingly to the stages. It opened like two, three months ago, so it's relatively recent.

Congratulations.

Congratulations.

Thank you. And the each of these sites has links to various appearances. And probably my most public statement to date is the interview with Eileen Kelly on Ongo Mental. And it was a really good interview. I think it has about 250,000 views now. Probably this is where lay people find me. And then they contact me with questions and emails and things like that, which I get.

Well, thanks so much for joining us, Dr. Glinker. It was really a learning experience. And again, thank you for your good work work here.

Well, thank you for your interest. It's a pleasure and good luck to you. Thanks.

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