Interviewing Well For Psychiatry Residency & Beyond

On this week’s episode of The Psychiatry and Psychotherapy podcast, we will be covering a special topic—interviewing well—for psychiatry residency, and even in other interviews post residency. I am interviewing Neal Christopher, a 4th year, chief resident and the host of a podcast for the APA, The American Journal of Psychiatry Residents’ Journal Podcast. 

Know yourself 

We wanted to talk about how you evaluate the program—how you interview the program—from start to finish. 

To understand your values, you can use the Acceptance and Commitment Therapy principles. Think in terms of what thoughts or ideas you want to move towards, longterm, in your life. What kind of person do you want to be? Also, consider what you want other people to think of you. What do you want to be said about you? When you are particularly angry or anxious, it is usually because a value you have has been violated. It’s an unconscious process normally, but if you pay attention, you can tell what your value and what is important to you. 

Notice your mentors, bosses, famous people in your career, and write down the attributes you like about them. When you find yourself drawn to a person professionally, notice what you like about them. Now consider how these things you like about other mentors are things you yourself could work towards and embody.

What kind of jobs would you do for free? 

Write down all of these attributes. These are things you value, and they will be things you’d value in a future psychiatry program. 

Know the program

Now that you have written down your values and research the programs. 

Write down questions you have for the program. Get very specific about your interests and how the program will train you to be the best psychopharmacologist, psychotherapist or researcher you can be. 

Check on the culture of the program. Is it healthy? When you go out to the dinner, watch the residents and how they act. Are they excited, sober-minded? How do the faculty treat each other? If the residents are both realistic and also passionate, it’s a great sign. Of course they will be tired as first and second years, because it is a time-consuming program. But overall, look at the residents to get a good gage on the program.

Each program will have strengths and weaknesses, and it’s important to be honest about what they offer so you can make a choice that will be good for you for the next few years. 

Another important thing that not everyone does, but is helpful in you determining your desire to be there (and will help in the interviews) is to research the faculty and supervisors before you go. Have they written articles? Do they have a podcast? Twitter? A published work? Youtube videos? What are their passions? Go beyond the bios on the website, if you can, and see if their values are similar to yours. 

The Actual Interview

In a medical school interview, you are just hoping that they don’t say no and let you into the program. When you get to your residency programs, everyone is pretty much equally qualified. When you look at the data of what stands out in psychiatry, it basically comes down to personal likes and dislikes—how you come across in the interview.  

People always ask “what part is the interview?” The truth is that everything is the interview—the dinner, the “actual” interview, the social event before and after, and everything in between. Even the way that you treat the program assistant is important; we have disqualified people from joining our program based on the way they treated our program assistant. If we are giving a tour of the facility and the person is on their phone or not engaged in the conversation, that tells us they aren’t as interested in our program. 

One piece of advice I always give people is very practical: exercise the day before your interview, set two alarms, and wake up early. 

One of the unique things about interviewing for a psychiatry program is that you’re interviewing with people whose entire job is...understanding people. That means that the more you can let them in to see your passions, your passion about your future career, about your goals, what you liked about their program and why you feel you’d be a good match, the better the interview will go. 

The goal is no longer to give rehearsed answers for what you think the programs want to hear. The goal is to be yourself so that you can find a good match, and so can the program. They can remember you, know you, and get a sense of what it is like to work with the real you. Demonstrate a highly-developed interest that will make you stand out from the crowd. Rather than try to answer questions, try to connect with the person as a person. Demonstrating empathy (understanding their perspective or thoughts) will go a long way.  

When you have already covered your values for yourself, and the values you have identified and appreciate in the program you are interviewing for, it is much easier to stand out from the crowd because you’re already demonstrating interest and knowledge of the program, and of yourself. 

They will ask you questions, and you should have well-rounded, empathic and intelligent answers that are real and true. Most often, they will ask you about: the greatest thing you have overcome, what your weakness is, and how you have demonstrated resilience. 

One thing Dr. Christopher did to prepare was recount stories about patients he’d learned from. Also, it’s important to be able to describe how you handle conflict, and any issues you’ve had in the past. 

As an interviewer, here are some things that impress me:

  • Thoughtfulness

  • Some insight into what it will be like to be a psychiatrist

  • Have done some independent reading, podcast listening, etc. 

  • Have some link to the area or some reason for being in the location

  • Congruent emotional expression

Take notes on your trip home, after each interview. Once you’ve gone on ten or twelve interviews, they all start to blur together, so it’s important to note details so you won’t forget. Those details on who you met and what you liked will come in handy when you write your thank you cards. Write somewhere private, as raw as possible, any thoughts, feelings, body sensations, and even fleeting thoughts about the program. Try to do this in private before talking to others who also were at the program before, so you can get your own ideas on paper.  

When looking at post-residency job offers (and in my application to a residency) I paid attention to the quality of the people I would have supervisors. I wanted the most competent, smartest and most respected psychiatrists and psychotherapists to continue to mentor me.  Choose your supervisor carefully. It’s incredibly important who your supervisor is and if you want to spend your next few years learning from them. In my opinion, brand and money are less important than the quality of the supervisors you will have. Are the supervisors people you would like to become?  

In conclusion

 After clearly identifying your values, you are looking for alignment in residents and faculty.  When you go on interviews, you are also interviewing them. You are looking for a good match, but also even if you don’t think it is a good match you are looking to build relationships and contacts for the future. Everyone you interview can become a resource and someone to learn from and grow from. So take notes, get contact information, read about them and what they are into, and consider them as becoming some small part of your network in your journey forward.  Uniquely in psychiatry, we value relationships, and consider the interview trail as a place to create relationships.  

Link to Dr. Neal Christopher’s Powerpoint

Therapeutic Alliance Part 5: Emotion

David Puder, M.D.

On this week’s episode of The Psychiatry and Psychotherapy Podcast, we will be covering part five in the therapeutic alliance series. I will be talking about how to build a therapeutic alliance early on with patients through helping them process emotions. 

This series is dedicated to my mentor, Dr. John D Tarr.

Here are the previous episodes on therapeutic alliance. They do not need to be listened to in order: 

Episode 028: Therapeutic Alliance Part 1

Episode 032: Therapeutic Alliance Part 2: Meaning and Viktor Frankl’s Logotherapy

Episode 036: Therapeutic Alliance Part 3: How Empathy Works and How to Improve It

Episode 041: Therapeutic Alliance Part 4: What is Transference and Countertransference? 


Emotions & Connection

Therapeutic alliance, the relationship between the mental health professional and their client, continues to be one of the most important aspects of therapy. Experiencing connection with the patient is absolutely paramount, as hundreds of studies have shown us—therapeutic alliance alone can determine the outcome of therapy, positive or negative. 

I continuously talk to the medical students and residents  in my program about developing connection with their patients. Often, developing that connection can be difficult if we don’t fully understand how emotions work, how they feel, and how they can help us empathize with even the most difficult patient in our practice that we can’t quite seem to understand. Emotions are also what help our patients feel connected to us and be able to establish healthy connections with others. 

People often think of emotions as ethereal, complicated depths that are difficult to explore. They are actually just adaptive physical reactions to stimuli. There are a few main categories, and as we will discover, they are concrete and identifiable. Usually, in a healthy therapeutic alliance, they can be discussed, and even when emotions are painful to express or linked with traumatic memories, they can be disarmed and understood. 

Problems in affect

Many patients come into our offices, and one of the main commonalities is their inability to control their emotional affect. They might not be able to control their highs and lows—they have anger, anxiety and depression that they don’t understand, and it often feels like it has taken over their lives. When you begin to listen to their story, you can identify those recurring emotions and help them identify their triggers and what emotions feel like in their body. Sometimes a patient has been in the mental health system for so long that they might easily label themselves as “depressed” or “anxious” without really connecting to the meaning any longer, or how that actually affects them. 

Early childhood plays a large role in our ability to understand and regulate our emotions. As an infant, we learn how to understand, label, or tolerate emotional responses, but if we don’t, instead we oscillate between emotional inhibition and extreme lability. Often complicating this is an early trauma or loss, which creates a neurobiological sensitivity and vulnerability, predisposing us to future stress.  

As therapists, when we continually help our patients label their emotion, we can help them identify and begin to get in touch with those emotions in a way that gives them a feeling of control of again. Once we help them identify their emotions, we can help them uncover the meaning behind those emotions. 

Epigenetic studies have shown that our early-life emotional environment will even change the expression of different genes in the body. Our attachment experiences shape the early organization of the right brain, which is the neurobiological core of the human unconscious. 

If, as therapists, we can create healthy attachments with our patients, we can help them reorganize their emotional life and responses to stimuli. With a positive therapeutic alliance, as the patient discusses distressing occurrences in their lives, their negative emotions get re-metabolized in a healthy way.

“Awareness of the self is minimal unless self is threatened.” - Kohut

What is emotion? 

Emotions and feelings are built from reactions that promote survival or wellbeing of the person. Our feelings come first in early development and retain a primacy that subtly pervades our mental state for the rest of our lives. We are born with the function of emotions so we can solve automatically (without logical reasoning) many of the basic problems of life. For example, on my daughter’s first day of life, she displayed anger when trying to get milk and having difficulty latching on. Anger gives us the energy to overcome obstacles and move toward goals. We almost always want to approach something pleasurable or withdraw from something that would cause us anger, fear, or disgust. Emotions also have the power to activate or deactivate our immune system. 

Emotions play out in the body

Emotions deeply affect the HPA axis, metabolism, endorphins, and even inflammation. The brain lights up in MRIs in different places based on our emotional states. People can often write them off as inconvenient, or even suppressible, and many patients don’t realize how important they are to pay attention to. 

Emotions are simply physical reactions—they are movement towards action, often to withdraw or move towards something. 

I like to think of emotions as problem solvers. Emotions are not good or bad—they have a logic of their own and are responding to a situation. We often think of anger and shame as “bad,” but they are adaptive mechanisms. When we realize this, we can begin to look at the information and the logic and be curious about them. 

Early emotional development

The whole of childhood development is unconsciously focused on the enhancement of self-regulation (Fonagy and Target). The essential task of the first year of human life is to create secure attachment bonds between the infant and their primary caregiver. In order to enter into this communication, the mother must be psycho-biologically attuned to the dynamic shifts in the infant's bodily-based internal states of central and autonomic arousal. The attachment relationship mediates the dyadic regulation of emotion, wherein the mother co-regulates the infant's postnatally developing CNS and ANS. 

On fMRI, adult attachment activates in the right inferior frontal cortex, which is also involved in control processes and emotional regulation (Buchheim et al). Relational experiences are encoded in the unconscious internal working models in the right brain.

"The self-organization of the developing brain occurs in the context of a relationship with another self, another brain." - Allan Schore

Split Brain Patient

A split-brain patient was able to read words with both hemispheres, although he could only speak through his left hemisphere. When something was shown to the left hemisphere, he could tell what the stimulus was and whether it was good or bad. When the right hemisphere was presented the stimuli, he was unable to say what it was, however, he could say if it was good or bad. For example, a picture of a devil was "bad" whereas a picture of his mother was "good."  Somehow, the emotional significance of the stimuli leaked across the hemispheres. (Ledoux, 1996)

When instructing the right hemisphere to wave, the patient would wave, but when asked why he was waving, he would make something up, like someone he knew was waving at him. When the right hemisphere was told to laugh, the left made up the reason, "you guys are funny guys." 

This study shows that the emotional processing can take place outside of awareness, unconsciously.

The power of therapeutic alliance

“The most intense affects make us the most vulnerable. In failures to be understood, we feel disconnected. This may induce a profound shame. Shame precedes rage. Moments of disconnection are inevitable. How does the patient learn to tolerate such vulnerability?” - My mentor, Dr. John Tarr

There are three types of therapy for borderline personality disorder which work, which can seem very different, but have close relationships that form over a protracted period and focus on emotions in different ways.

  • Dialectical behavioral therapy

  • Transference therapy

  • Mentalization based therapy

As therapists, we focus on the affective dynamics of the right brain, which are activated during a therapeutic alliance. The therapeutic alliance forms in a similar way as the implicit attachment regulatory function matures. The empathic therapist's capacity to regulate the patient's arousal state within the affectively charged non-conscious transference-countertransference relationship, is critical to clinical effectiveness (Shore).  

When we pay attention to our patients’ body movement, posture, gestures, facial expressions and prosody, we can help them adjust their emotional state and develop healthy connection with someone even within their trauma story. Our affect attunement will regulate the patient's affect.  

Helping someone identify their emotions with words, and connect them to the body sensations that tell us what emotion they are feeling, is incredibly important. If a patient is intellectual, has been in therapy, or is even a mental health professional, they may try to make their emotions purely intellectual. If they haven’t been able to identify their emotions at all, or don’t have names for how they feel, it can also help to verbally identify where their feelings are coming from and why they are adaptive. 

As therapists, it is our job to help our patients put names and body sensations to their emotions. When someone ignores their emotional cues, or has experienced a traumatic event and is in shutdown mode in certain areas, they might not have been able to be congruent with the emotion expression they needed at the time. 

Listen to: Emotional Shutdown—Understanding Polyvagal Theory

Microxpressions are how emotions are expressed on the face in micromovements. When we can identify our patients’ microexpressions, we can help them begin to identify their own emotions and get back in touch with how they are feeling. I’d highly recommend any therapist study microexpressions. I dive more into microexpressions in three different podcasts you might want to listen to: 

  1. Microexpressions to Make Microconnections Part 1

  2. Microexpressions: Fear, Surprise, Disgust, Empathy, and Creating Connection Part 2

  3. Using Microexpressions in Psychotherapy

How do you connect with a patient in their emotion? 

Here are a few things I like to use and/or do in order to make sure I am developing a real connection with my patients to create a positive therapeutic alliance. My main goal in these questions is to help my patients understand that their emotions all have a goal—they are feeling this way for a reason. Emotions aren’t nonsense; they have a purpose. When we help them identify the purpose, they can begin to untangle the event that made them emotional, and the meanings they assigned to that event. When we, as therapists, are with them in that, mirroring their emotions, we can build a bridge between the right and the left brain, and a bridge where the patient is in healthier connection with others. 

    • Check in with yourself before you go into any therapy session. How are you feeling? That way, you can have a baseline of what is transference, what is the patient, what is your own emotional state as you feel into their experience. 

    • Once you enter the therapy session, listen, feel and watch the patient’s moment to moment change in emotions. As you see and feel the shifts, you will be able to tell what words, events, or emotions might be triggering for them. 

    • Try to enter a bit into their feeling, be present with them, mirror the emotion/feeling, use their own words as you repeat back to them for clarification.

    •  Ask them to find their own words to describe how they are feeling.

    • If you don’t understand why they are sad, then stay with the topic, ask them more questions, have them deepen your understanding of it. Once they feel you truly understand the affect will change. When people feel heard, deeply understood, it is pleasurable to them, and they will begin to shift their own emotional experience.

    • Give the patient the power to own their emotions.

    • I like to remind them:

      • “You are entitled to your emotions. We will put them to words. We will not necessarily act upon them.”

      • “What does your emotion want to accomplish?”

      • “Where do you feel that _____ in your body?”

    • When they experience shame, I like to talk about it with them:

      • “I can understand why talking about this must be difficult.”

      • “Perhaps as you talk about this you feel___.”

      • Try to find the adaptive function: 

        • “I hear switching to a new doctor is hard, I think that is a common experience, I think it is adaptive to be hesitant at first in what you share since we are just meeting."

      • My mentor, Dr. Tarr, when he talks to patients that are feeling shame, says, “I am particularly concerned when embarrassment, self-consciousness, or  apprehension about disclosing something that reduces self-esteem makes a patient hesitate to talk about something, or induces excessive inhibition about sharing-ness. The patient may anticipate being shamed. 

        • He will say things like: 

          • “When you feel uncomfortable in thinking about something, or like avoiding a topic, it will be valuable for us to become aware of your hesitation.”

          • “Of course it’s hard to share with me something that you feel disappointed or discouraged about; what undesirable feelings might you have if you were to talk about it?”

          • “There are some things we would much rather not bring into the open; we can beneficially learn a lot about what makes us feel  distressed about ourselves.”  

          • “It is natural to wonder if I will be disappointed in you.”

          • “Revealingness about oneself is often difficult.” 

          • “Do we ever really want to say out loud all the things that we think about and feel? Learning about uncomfortableness can be very worthwhile and helpful.”

          • “Sometimes feeling naked and exposed makes it hard to talk and be open.” 

          • “Even though we try to be open with each other, of course we sometimes feel inhibited and cautious.” 

          • “Perhaps you felt a little ashamed as you were thinking about that. Our learning together about your distress that may be embarrassing can be most valuable and helpful to us.” 

          • “A feeling of being looked down on by someone can be quite humiliating, let’s look at how that develops.” 

          • “Are you afraid that you may be disappointing me and that I may not feel approving and accepting of you?”

          • “Sometimes we feel that being looked at will disappoint someone or oneself.” 

          • “It is worthwhile to try as much as possible to have unconditional positive regard and self-acceptance most of the time.” 

    • When they experience anger and frustration, I like to say things like:

      • “Would you say as you mentioned this you feel frustrated?”

      • Find the adaptive function of anger: “Your anger here seemed to have the goal to protect you and your family.” 

      • “Your anger likely kept you alive!"

    • When they experience sadness, I like to say things like:

      • “Perhaps you are feeling sad as you say this?”

      • Find the adaptive function: “It makes sense that you feel sad here, I think crying and feeling sad shows how much you valued your dad and therefore the loss hurts that much more."

    • When they experience disgust, I like to say things like:

      • “I am wondering if you feel disgusted by this?”

      • “I hear you feel disgusted…?” (with a questioning tone)

      • “Perhaps as you discuss this you feel some revulsion.”

      • Find the adaptive function: “Feeling disgusted by how your sisters turned on you and cast you out of the family makes sense, maybe it sickens you to see the level of their resentment and bitterness."

    • When they experience fear, I like to say things like:

      • “I hear a deep concern or perhaps fear regarding this.”

      • “Might there be a deep concern or perhaps fear regarding this?”

      • Find the adaptive function: “After your traumatic event, it makes sense that you would no longer want to put yourself in that situation; it sounds like you are trying to protect yourself."

      • As that happened what did you fear I might think or feel?  

Here is a chart to help you identify different emotions and how they feel in the body:

(due to formatting issues it is in the resource library under resources for episode 062- sign in here)

In conclusion

Connecting with our patients in their emotions is what creates a good therapist. We want to give someone the ability to feel heard and understood. The goal is for our patients to feel connected, because feeling connected, even in distress, brings pleasure. We want to create the understanding that connection can be safe and give pleasure, because we want them to be able to develop healthier attachments to others in their lives.

Deciding for Others: Involuntary Holds and Decision Making Capacity

 This week on the Psychiatry and Psychotherapy Podcast, I am joined by Dr. Mark Ard, a chief resident physician at Loma Linda University’s Psychiatry program, to talk about holds and capacity evaluations as it relates to medicine and psychiatry. 

Katie Cho, D.O., Mark Ard, M.D., David Puder, M.D.

Why is this important for mental health professionals?

Medical ethics is an important component of healthcare, and oftentimes, physicians and family members have to make difficult decisions with insufficient information or time. As a psychiatrist, it is very common to be consulted on how to help patients who struggle to keep themselves safe, others safe, or are incapable of leading their best life. In regards to psychiatric detainment, there are specific laws in place protecting both physicians and patients.

Understanding the laws, regulations, and practices of involuntary treatment is important. Essentially, a determination is made that a patient is unable to make a rational decision for reasons that become apparent through the evaluation process; they are not able to display the capacity necessary to make the decision.

As a physician, you must justify these decisions to yourself and in documentation based on the evidence presented. Fully understanding the ethical underpinning of these holds with a capacity evaluation really puts it all together and helps with appreciating why it might be appropriate to hold somebody in a hospital setting.

Probate vs Lanterman Petris Short Act (LPS)

Probate Conservatorship

  • When a person is taken to court to present evidence that he/she cannot make decisions for themselves in broad areas, including medical and financial decisions, a family member or state representative can be granted legal authority to make such decisions on the person’s behalf. This is the idea of probate conservatorship. 

  • Dementia powers are also granted at times, allowing a probate conservator to make the decision to admit the person into a locked dementia facility for protective reasons, ensuring patient safety and well-being.

  • Persons under a probate conservator do not need a psychiatrist, though a psychiatrist’s assessments may carry weight when the patient is taken to court. 

  • The process of obtaining a probate conservatorship is prolonged. It starts with a petition to the court and includes a long waiting list that can be extremely costly.   

Lanterman–Petris–Short (LPS) in California

  • When a person has a severe mental illness or chronic alcoholism that is gravely disabling, meaning the person is unable to make appropriate decisions to provide basic needs for themselves, a conservator may be assigned by the court to make all decisions in regards to housing, medications, hospitalizations, etc. on their behalf. 

  • Psychiatrists must initiate the process of obtaining a conservator on a patient’s behalf, and legal proceedings take place in mental health court.


Much of what will be discussed are based on California laws. You should become familiar with the regulations and laws established in the state in which you practice. 


Voluntary: The patient agrees and chooses to stay at a treatment facility for further assessment, evaluation and management.

Involuntary: The patient refuses the option of being assessed, evaluated, and managed at the treatment facility despite being a danger to themselves, to others, or unable to provide for themselves. Involuntary holds means that you the provider think that they must receive care under direct supervision, ultimately at a locked inpatient facility.

5150: Involuntary 72 Hour Hold

If the evaluator deems the patient, “…as a result of a mental health disorder, is a danger to others, or to himself or herself, or gravely disabled…[the patient may be held] up to 72 hours for assessment, evaluation, and crisis intervention, or placement for evaluation and treatment in a facility designated by the county…if the person can be properly served without being detained, he or she shall be provided evaluation, crisis intervention, or other inpatient or outpatient services on a voluntary basis.”

Patient diagnoses are often mistakenly used to justify a 5150 involuntary hold. However, diagnosis does NOT justify the detention, but rather the evidence of behavior or risk. Of note: patients are allowed to refuse medications while hospitalized. Involuntary administration of medications involves a completely separate court process. 

Patients are often told incorrectly that they “are on a 72 hour hold” then they will be released. With treatment and evaluation, a patient may require hospitalization for shorter or longer than the 72 hour period. As the hold expires, the patient may choose to be voluntary or the hold may be extended, for example in a patient with catatonia, suicidal depression, or current mania to keep the person safe may take 1-2 weeks.  

5250: California’s 14 day extension

After a patient on a 5150 hold “…has received an evaluation, he or she may be certified for not more than 14 days of intensive treatment related to the mental health disorder or impairment by chronic alcoholism.”

Patients are kept longer for continued evaluation and treatment when their treating psychiatrist believes that the patient’s mental health disorder has not resolved enough to where the patient demonstrates the capacity to be of no danger to themselves, others, or provide for themselves. The extension is up to 14 days. This allows for more patient protection with an automatic probable cause hearing for the patient so that the court can determine whether the psychiatrist has met a probable cause threshold. The patient also has a right to legal representation.

5300: 180 day extension for homicidal ideations

There can be an extension up to 180 days if a patient poses a significant danger to others as psychiatrists continue to evaluate and treat.  This is very rare in my experience.  

1799.111: California Law

There is a subsection of California law that addresses patients being treated in facilities that have not been designated as a psychiatric hospital. This law protects a medical doctor for detaining a patient against their will in a hospital facility for up to 24 hours if their mental disorder is presenting a danger to themselves, to others, or is deemed gravely disabling. 

The biggest problem with this law is that it is often near impossible to find placement in a psychiatric hospital within 24 hours. It may be beneficial for medical doctors to consult the psychiatric service at their facility when a person is deemed medically stable.

Patient populations often considered for holds

Evaluations for detainment are on a case by case basis. The following patient groups may have higher likelihood of involuntarily hospitalized:

  • Schizophrenia: The level of violence is increased during the first psychotic break. It’s to be noted, however, that somebody with schizophrenia is more likely to be a victim than a perpetrator of violence. 

  • Bipolar Disorder: prior to the advent of Lithium and other treatments, 20% of patients with bipolar disorder committed suicide. Psychiatric hospitalization are lifesaving, especially patients in manic episodes who are often times unaware of their own lack of capacity.

  • Suicidality: Intent, plans, means, psychological motivation, and lack of support increases risk of life threatening events. In fact, 10-15% of patients hospitalized for depression will attempt suicide.

  • Anxiety: Especially those with suicidal ideations can increase risk of life threatening events.

  • Substance abuse: Disturbance of frontal lobe function can increase impulsivity and risk to self and others.  

Informed Consent vs Capacity 

Informed consent is based on the principles of autonomy and privacy. There are seven criteria that define informed consent:

  1. Competence to understand and to decide.

  2. Voluntary decision making.

  3. Disclosure of material information.

  4. Recommendation of a plan.

  5. Comprehension of terms (3) and (4).

  6. Decision in favor of a plan.

  7. Authorization of the plan. 

Implied consent is defined as the signs, actions, facts, or inaction that raises the presumption of voluntary agreement—as in a person sticking out their arm in front of a health provider holding a needle implies consent for a blood draw.

Against Medical Advice (AMA) describes a person making a decision to leave a health care facility against the advice of their medical providers. Even in this case, the patient must demonstrate the capacity to make that decision.

Capacity can be determined by any medical provider, not only a psychiatrist. There are five criteria that define capacity:

  1. Expressing a decision. Even a patient who is delirious that decides he would like to leave the hospital against medical advice would meet this criterion. Often the first thing we need to do is clarify what the patient wants.

  2. Understand relevant medical facts—at least at a layperson’s level be able to comprehend their condition and treatment recommendations.

  3. Appreciate risk benefits and alternatives at a level appropriate to the choice being made.

  4. Assessment of their ability to reason and rationalize through the first three criteria.

  5. Is the decision consistent with the patient’s values? Inconsistency and rash decision making usually indicates limited ability in criteria two and three

Other considerations when evaluating capacity: 

  • The world view of a patient may be more in line with alternative treatments. Balance should be sought to allow patients to make alternative decisions versus helping them reach their predefined goals. 

  • There may be a need to de-escalate situations and empathize with patients that are making irrational decisions based on an especially bad day. This is when psychiatry consults may be especially beneficial. 

  • Depression changes the way a patient may evaluate the world, making accurate assessments about their current situation and the future difficult.

Addressing Incapacity

When patients cannot demonstrate capacity, we are often faced with three unappealing options:

  1. Allow the patient to be discharged Against Medical Advice. This in inappropriate, as an AMA assumes they have the capacity to make that decision. Just because a patient signs an AMA form, does not mean the hospital or staff are protected from a claim of negligence.

  2. Request that a psychiatrist place an involuntary psychiatric hold. This also may be an inappropriate request, as primary teams are often asking the psychiatrist to inappropriately detain a patient trying to leave or refusing treatment, without a mental health disorder causing the incapacity. Psychiatric detainment is only meant to keep patients in psychiatric hospitals. Involuntary treatment requires a separate judicial process. 

  3. Detain the patient out of an obligation to provide care while avoiding harm. There are no clear legal statutes on this topic, but significant case law showing that physicians and hospitals who justify their interventions are not held liable for harm.

    1. Dr. Erik Cheung, a psychiatrist at UCLA, recently published a paper discussing a policy at UCLA that allows patients on the medical floors to be detained against their will if they are determined to lack decision making capacity. There is no formal law that addresses such situations outside of individual facilities.

In every instance, whether the patient has capacity or not, document your decision thoroughly. Note any and all information about your encounter and assessment, including emergencies if they existed, a patient’s ability to consent, and the benefits of treatment. 

Who Decides?

Give it time: Determine the emergent status of a capacity decision. Do you need to make a decision right now, or can this patient be observed with as needed medications until they demonstrate capacity? 

Durable Power of Attorney or Advance Directive: Patients may name decision makers and lay out ground rules for providers to follow should they become incapacitated.

Substituted judgement: When an identified decision maker attempts to make the choice the patient would make. Different states have different rules about the order to seek substituted judgment. In California, we turn to next of kin—spouses, adult children, parents, other family members, and friends. At times it may be necessary to get your facility’s ethics committee on board.

Best interest decision: Consult with colleagues and make a best interest decision on the patient’s behalf. Document your decision thoroughly and with 2 signatures. 

Legality of Treating Incapacitated Patients

To patients, involuntary holds may be construed as assault, battery, and false imprisonment. Courts have historically supported physician’s actions, without consent, when the lack of demonstrable capacity has been shown and documented. Courts assume that a reasonable, competent adult would desire to be healthy. 

Some notable case laws include: 

  • Miller v. Rhode Island Hosp: A patient in a motor vehicle accident was forced to have a peritoneal lavage. Surgeons were sued by patient for assault, battery, and false imprisonment. Court ruled in favor of physicians because they acted in the patient’s best interest.

  • Youngberg v. Romeo: A mother institutionalized her disabled adult son and later sued the hospital for using bodily restraints. Court established The Model Penal Code which allows “an exception from the assault statute for physicians…who act in good faith in accordance with the accepted medical therapy.” Court found there is a necessity to utilize physical detainment if you’re trying to do the right thing.

Utilize holds by acting in the patient’s best interest and document thoroughly. Do what you, as a provider, think is best even in very difficult situations. Empathize with those who are deemed incapacitated, and talk about goals that are beyond just going home; empathize and educate.

Final Thoughts: 

We hope these often confusing topics are somewhat clarified in this article and podcast episode. First and foremost, building a strong therapeutic alliance (strong bond, common goals, mutual trust) allows for us to not need to use holds as frequently as we otherwise would need to. Sometimes, however, to keep a patient or community safe, we have to imagine what we would want for ourself or our children in a similar situation, if we were manic, psychotic or about to kill ourselves, what would we want done for us? In this case the most empathic thing to do, is to protect the patient from allowing an acute and treatable disease that would end their life. Care and kindness must be present in the midst of those safe measures, or the hold itself can become another trauma.  

“The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; those who are in the shadows of life, the sick, the needy and the handicapped.” -Hubert Humphrey 

Genetics and Environmental Factors in Suicide

Jaeger Ackerman, B.A., Steven Kasperek, B.S., David Puder, M.D.

In the previous episode on Suicide, we discussed epidemiology, general risk factors, and associations of suicide with various mental health disorders. Now, in this second part of this series, we will focus on genetic and environmental factors associated with suicide.  The data here might be cold and distant, and so is the nature of suicide. It cuts at the core of families that have struggled with it. I have had many patients who have had family members commit suicide, and it devastates them forever.  

Struggling with suicidal thoughts is a burden and carries weight in those that live with it on a daily basis.  Our hope would be that those who struggle with suicidal thoughts would look for effective, evidence-based treatment.  Our hope for providers is to know more about suicide, be more comfortable in having discussions with patients, and feel more like an expert in both knowledge and the ability to empathize with patients’ distress. 

Genetic Links to Suicidal Behavior

For families that have seen multiple suicides, the burden and angst that comes with continuing to live without their loved ones runs deep.  With regards to genetics, suicidality has been noted to cluster in certain families, particularly families filled with mood disorders (Brent, Oquendo et al. 2002, Brent and Mann 2005). Further evidence for a genetic component comes from various twin and adoption studies that have been conducted over the years. 

  • The Swedish National Registry, a study with nearly 84,000 probands, suggests a heritability pattern of between 30-50% (Tidemalm, Runeson et al. 2011). 

  • When corrected for transmission of psychiatric disorders that could be confounding factors, this heritability for suicidal behavior remains between 17-36% (Fu, Heath et al. 2002). 

  • To put this into a more concrete number, children of a parent who attempted suicide are nearly five times more likely to attempt suicide themselves than the average person (Brent, Melhem et al. 2015). 

Just to give you a frame of reference to things that are highly heritable include things like height, whereas things more complex like IQ have a lot more variation.  The heritability of height is approximately 80% (Yang et al 2010). The literature generally estimates IQ heritability to be between  40% and 80% (and generally less for children). However, it must be stated that heritability of IQ varies significantly by social class. Additionally, almost no genetic polymorphisms have been discovered that are consistently associated with variation in IQ in the normal range (Nisbett et al, 2012).  So in summary, the heritability of suicidal behavior is present but not very strong compared to things like height.

Lessons from Monozygotic Twins

A unique way of looking at just how significant genetics are for variance in suicidal thoughts and behaviors is through the use of a monozygotic versus dizygotic twin study. Monozygotic twins share all of the same genetic information because they come from the same sperm and egg, whereas dizygotic twins just share the same in utero environment. Data from the Swedish Twin Registry showed that if one monozygotic twin committed suicide, than the rate for the other twin committing suicide was 6%, as compared to 2% for dizygotic twins. A similar, but smaller study from the Danish Twin Registry showed an even greater disparity, with rates of 35% for monozygotic and 0% for dizygotic twins (Juel-Nielsen and Videbech 1970, Pedersen and Fiske 2010).

Does Adoption Change these Results?

Another factor that needs to be addressed is the difference between pure genetics and the influence of siblings or twins sharing the same home environment, with regard to influence on suicidal behavior. Here, we look to adoption studies that reveal that suicide in biological parents had similar effects on offspring suicide in the non-adopted and adopted, suggesting the primary effect of parental suicide is hereditary rather than mediated by the post-natal environment (von Borczyskowski, Lindblad et al. 2011).

What Genes Increase Suicide?

With the evidence for a genetic component in mind, it is little wonder that much research has been done to try to elicit more specifically what genes might be related to suicidality. Over 200 genes have been reported as being associated with suicidal attempts, and there has been exponential growth of discovery of candidate genes in the past decade. Most of the individual genes that have been studied have been driven by biological hypotheses regarding rates of serotonin synthesis, serotonergic neurotransmission, and neurotrophic factors. These studies have produced inconsistent results (Anguelova, Benkelfat et al. 2003, Brezo, Klempan et al. 2008, Dwivedi 2010). More recently, there has been a shift towards looking at genome-wide association studies (GWAS) or familial linkage studies to try to find a genetic link. Some evidence, though not conclusive, points to a genetic tendency linked to a particular area on the genome of chromosome 2. Data gathered from 162 families diagnosed with schizoaffective disorder or bipolar disorder showed that family members within this cohort who had attempted suicide had a higher degree of genetic similarity at a specific are of chromosome 2, 2p12  (Willour, Zandi et al. 2007). This replicated similar findings from two previous studies of attempted suicide in pedigrees with alcohol dependence and in pedigrees with recurrent early-onset depression.

What Role Does BDNF Have?

  One set of genes to highlight as potentially interesting are Brain Derived Neurotrophic Factor (BDNF) and its receptor, NTRK2. BDNF is one of the neurotrophins that regulates neuronal survival, plasticity, and synaptic function (Morse, Wiegand et al. 1993, McAllister 2001, Tsankova, Berton et al. 2006). We have talked about how BDNF can be increased by certain medications, exercise and diet in prior episodes. BDNF has been shown to be modulated by stress through epigenetic regulation (Roceri, Cirulli et al. 2004). This is one example of many where early life adversity or other stressors can take the preexisting raw genetic data in our bodies and modify it to be more or less expressed through DNA methylation or histone modifications (Turecki, Ota et al. 2014). Beyond BDNF, there have been widespread changes in methylation patterns of neurotrophic and neuroprotective factors in the hippocampus and prefrontal cortex associated with suicide (Labonte, Suderman et al. 2013, Schneider, El Hajj et al. 2015). Specifically with BDNF, studies have looked at mutations in the gene, as well as expression of the protein levels in the brain, in association with depression and suicide (Youssef, Underwood et al. 2018). A polymorphism in the gene, Val66Met, is associated with an increased risk for depression. Suicide itself was not associated with this genotype, but lower levels of BDNF were found in the anterior cingulate cortex of the brains of individuals who had committed suicide. Further meta-analysis and systematic review of 23 small sample size studies shows no significant association of the Val66Met polymorphism and suicidal behavior, except when broken down by ethnicity. In that case, Caucasians and Asians are found to have an increased odds ratio for suicidal behavior of 1.96 and 1.36 respectively (Gonzalez-Castro, Salas-Magana et al. 2017). Overall we know BDNF is one thing that we can influence which provides some hope as we struggle to help those who struggle with suicidal thoughts.

Environmental Influences on Suicide

Beyond genetics, environmental factors and traumatic events are also associated with higher rates of suicide and suicidal thoughts. While not exhaustive, this list includes adverse childhood events such as physical or sexual abuse, witnessing domestic violence in the home, or being in the foster care system. Traumas throughout adulthood including divorce, rape or physical assault, serious accidents, and loss of pregnancy also contribute to higher rates of suicide. A large epidemiological study in Australia showed that a history of childhood sexual abuse was associated with a 3.79x greater suicide rate, while female rape or physical assault was associated with a 3.63x and 3.69x greater incidence of suicide, respectively. Other factors identified included being currently separated or divorced (2.38x), experiencing a serious accident (2.04x), and loss of a pregnancy (1.54x) (Statham, Heath et al. 1998).

The Third Factor: Choice

While genetics and environmental influences certainly are external factors associated with suicide risk, we want to emphasize that these are not the only factors. 

  •  The average rate of suicide is around 10 per 100,000 people years (1% of the population dies by suicide).  

  • If a monozygotic twin commited suicide, in the largest study, there was only an absolute increase in 4% compared to dizygotic twins.  

  • If you had 4x the risk of commiting suicide due to environmental factors, it would still be 40 per 100,000 people years.  

So there are factors outside of genetics and environment that influence suicide, and I would argue one of those is choice.  It is important to recognize the role of choice (we are not just a bag of genetics and things that happen to us, and actually thinking that way is harmful).

Thinking You Have No Choice is Harmful!

In studies where they try to convince one group that they don’t have a choice (by having them read that they are just doing things predetermined by their biology, genetics or environment), it leads to them:

  1. Being more likely to cheat (Vohs, 2008)

  2. More likely to conform to social norms (Alquist, 2013

  3. Reduced helping behavior and increased aggression (Baumeister, 2009)

  4. Not slow down after making an error to re-evaluate. (Rigoni, 2013)

Essentially, thinking you have no choice makes you more likely to do things that are not as thoughtful and decrease your frontal lobe function.

Furthermore, a recently-published Israeli study sought to elucidate the origins of suicidal tendencies by comparing patients of open wards in a psychiatric hospital (n = 59) to a control population (n = 65; N = 124). Notably, the study’s results clearly demonstrated in both groups a decreased sense of meaning in life (—0.82, p < 0.001) and lower amount of an internal locus of control (—0.49, p < 0.001) each were significantly correlated with risk of suicide. Simply defined, a life with meaning is one the individual feels is worth living (Frankl, 1984). The presence of meaning in one's life is essential to enduring adversity. Meaning in life is especially relevant to providing individuals with the ability to avoid harmful behaviors adopted in response to difficult circumstances. This underscores the notion that genetics alone do not determine the course of our lives. As indicated by the study, the interactions we have with our surroundings and the people in our lives are significant factors. From those interactions, we interpret and construct a meaning — a purpose (Aviad-Wilchek, 2019).

With this in mind, we encourage our listeners and readers to check out our final episode in the series on treatments and therapies that can be helpful.  In the final episode we will discuss how important it is to make choices to change your environment (like enrolling in a day treatment program) and get treatment, and how no case is hopeless.  Treatments we will discuss in the next episode that help people struggling with suicidal thoughts include:

  • Psychotherapy (especially with a strong therapeutic alliance)

  • Medication Management (treat underlying psychiatric issue)

  • TMS, ECT, Ketamine

  • Partial and Day-Treatment Programs (Mentalization, DBT)

  • Exercise

  • Diet 

  • Optimizing Sensorium

  • Treating Anxiety 

  • Treating Akathisia if present

  • Optimizing Sleep

  • Recognizing and Treating Substance Disorder

  • Taking Away Guns

Which Foods Are Good For Mental Health?

On this week’s episode of the podcast, I interview Dr. Drew Ramsey, a nutritional psychiatrist. When I was a resident, I saw him give a lecture on diet and how it affects our mood, and I’ve been wanting to interview him for a long time. He is the author of several books about diet and health.

I will be transcribing many of Dr. Ramsey’s thoughts here, and they will be mixed a bit with my thoughts as well.

Most people who work in nutrition don’t consider brain health and mental health when they talk about food—they’re mostly counting calories, macros, or working towards muscle gain or weight loss. One of the main things people miss is that our brain is fueled by our food. When we don’t feed it what it needs, it can’t function properly. 

One well known fact is that inflammation and depression have a bi-directional relationship (Kiecolt-Glaser, 2015)

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The mediterranean diet reduces risk of depression, stroke and cognitive impairment (Psaltopoulou, 2013)

We also know the healthy food increases BDNF, which is like miracle grow for the brain.

Treating patients with nutrition

Within the realm of mental health, patients often feel out of control, or hopeless, like their disorder or disease has taken over their lives. When they come to my office, it is often because they feel like they can no longer deal with their mental health issues on their own anymore. Many of my patients are surprised when I prescribe them diet and exercise regimens to help them. There are direct correlations between our sensorium and our mental health. When possible, in conjunction with therapy, it is usually my first course of action. My patients who follow the diet and exercise suggestions have experienced noticeable positive benefits. 

Another point Dr. Ramsey brings up is that with diet and nutrition, we can arm our patients with things that are within their control—eating healthy—and can give them the tools to make those changes in their lives. At a time when they feel out of control, such as when they end up in our offices, it can be helpful for them to have something they feel they can contribute to their well being. 

Many health fads come and go, and many diets claim they are a solution for depression. Some patients you meet will already be on a diet plan. Dr. Ramsey suggests it’s important to ask questions about why they chose their diet (keto, veganism, paleo, gluten free) in order to understand their motivations. 

The basic diet for depression or mood

Dr. Ramsey and I both agree that the overall healthiest guidelines for a good diet to feed the brain and improve mental health is the Mediterranean diet. If people are seeking health from food, there is a ton of information out there that is incredibly detailed and confusing. That’s why, for the purpose of this podcast and this article, we are going to keep it simple.  

  • Eat more plants than meat. This will help reduce inflammation. 

  • Avoid processed foods. 

  • 12 nutrients have significant evidence that they’re involved in relieving depression, and these nutrients are largely found in a spectrum of plant-based foods and seafoods. 

    • Folate

    • Iron

    • Long-chain omega-3 fatty acids (EPA and DHA)

    • Magnesium

    • Potassium

    • Selenium

    • Thiamine

    • Vitamin A

    • Vitamin B6

    • Vitamin B12

    • Vitamin C

    • Zinc

  • Eat leafy greens.

  • Try to maximize nutrients to calorie count.

  • Eat higher quality meats.

Here are a few, brief notes Dr. Ramsey mentioned in the episode about specific foods: 


EPA and DHA are the two fats we need to focus on within the omega 3s realm. DHA is the longest fat that is transported into the brain. EPA is a natural blood thinner and is full of anti-inflammatory agents. Different seafood, nut and plant-based fats are also excellent sources of omega 3s. 


Nuts are incredibly healthy for you. Most people feel like nuts are too fattening and calorie dense to eat, but they are great sources of protein, fats, and slow-burning carbohydrates. They’re also packed with minerals. Our brains are made predominately of fat, so eating high quality fats, like organic nuts, is a great way to feed our brains. Try to buy raw, organic nuts if you can. 

Organic Foods

For many people, organic means unaffordable. However, we know that pesticides are neurotoxins. There isn’t a tremendous amount of long-term data out there yet that they are extremely damaging, however, try not to eat them, because they obviously aren’t healthy for you. There is a ton of pesticide residue on produce. Try to go organic, if you can afford it, and if not, clean them well before you use them, usually by soaking in saltwater, water with vinegar, or another fruit and vegetable cleaning solution. The Dirty Dozen and the Clean Fifteen are good lists to figure out what you should be buying organic, and what may be okay to just purchase and clean thoroughly, if you need to. 


Dr. Ramsey says that eating mussels and clams a few times a month is an excellent way to feed your brain because of their high vitamin B12 content. 


Beans are inexpensive sources of protein, fiber and carbohydrates. They are incomplete proteins, but they are still a good choice because of the fiber content. 

Dark chocolate 

Dark chocolate has tons of health benefits. It’s plant based, fermented, gives you energy, and is good for your brain. Only one mineral has ever been shown to reverse memory decline, and dark chocolate has it. 

It’s also a great example of a core principle of psychiatry—food should be filled with pleasure, joy, and not angst. Dark chocolate is enjoyable to eat.

Mindful eating  

Because food is pleasurable, pausing after a few bites to breathe and relax, can slow down our eating and increase our enjoyment. It also gives us a chance to chew our food, which is healthier for digestion.  

Food should be about love. Making food for friends and family. Eating meals together increases connection. Exploring creative cooking (and sometimes making mistakes and being ok with that!) Exploring delicious tastes and textures.

Here is my other episode on diet: Diet on Cognitive Function, Brain Optimization

Lithium Indications, Mechanism, Monitoring, & Side Effects

Lithium Indications, Mechanism, Monitoring, &amp; Side Effects

Lithium is indicated for a number of things. Most clearly, as a mood stabilizer in bipolar spectrum disorders. It is unique among mood stabilizers in that it is very robustly anti-manic. The medication treats and prevents manic episodes from occurring, providing fairly robust prophylaxis against mood cycling. Lithium is also effective in treating bipolar depression, though not as effectively. Very few of the other mood stabilizers are effective for the depressed pole of bipolar illness.

Link to Resource Library

Why Lithium is a Great Option for Treating Bipolar, with Dr. Walter A. Brown

This week the Psychiatry and Psychotherapy Podcast is joined by Dr. Walter A. Brown, Clinical Professor Emeritus in the Department of Psychiatry and Human Behavior at Brown University, author of the brand new book “Lithium: A Doctor, a Drug, and a Breakthrough”.  In order to capture the full experience of this week’s episode, I’ve posted a transcript of my interview with Dr. Brown. 

 Dr. Puder: Tell me a little bit about yourself and how you got interested in this topic. 

Dr. Brown: I’ve been a psychiatrist for more than 40 years. A lot of my career has been as a full-time academic, doing research into various features of biological psychiatry, with a particular emphasis on the endocrine system as it applies to psychiatric illness and psychopharmacology.  I am also interested in the history of psychiatry. 

I came across Lithium early in my residency training. I did my first year of residency training in 1968-69. One of my first patients was somebody who was a manic-depressive, what we now call bipolar, and he was very difficult to manage. As I say in the introduction of my book, one of the things he was always trying to do was to leave the locked ward he was on in the hospital in New Haven, and go to Washington to meet with the President; it was my job as a first year resident to stop him from doing that. Several times a week, a group of nurses and I would have to restrain him and he would be injected with a sedative, but none of that really helped the fundamental features of his illness. 

At one point, as I was arriving at the hospital (I used to ride my bicycle to the hospital) I saw this man, who I refer to in the book as Mr. G, taking off across the parking lot and heading for the train station. I intercepted him on my bike and brought him back to the ward, but the people in charge there felt that he was just too difficult to manage and so he was transferred to the local state hospital for long term care. It was two years later that I saw him at one of the outpatient clinics. He was doing fine; he was no longer hospitalized, he was no longer insisting on meeting the President, and his periodic attacks of mania and depression had stopped. I chatted with him briefly and he told me he was on this new drug: Lithium, and clearly, it had really changed his life. After that, I had, like other psychiatrists of that era, many experiences with patients where they were taken off of whatever stuff they were on to treat their manic and depressive attacks and put on Lithium and they did very well.  

I became curious as to how this drug was discovered, how it worked, and I started looking into it. At the same time, one of the things I do in the department of psychiatry at Brown is teaching a seminar on classical papers in psychiatry; papers that change the field. I came across, in the context of that teaching, John Cade’s original report of the use of Lithium in mania. It was gripping for me because Cade was an essentially young, unknown Australian psychiatrist working in 1948 when he did this study in a remote hospital outside of Melbourne, Australia. He had no grants, no collaborators, he had no formal research training and yet he managed to come up with what is arguably the most important discovery in psychiatry; certainly of the 20th century. I was curious as to how this guy, who is still not a household name, managed to come up with something so important basically on his own.  

So I looked into the history of his discovery and what happened afterward. The more I learned about this, the more interesting the story became for me, and so I really decided to write it down. What I started doing was writing a biography of John Cade. There hadn’t been one by that time and I thought: “given the importance of his discovery, it would be good to take a careful look at who this man was”  But as I started to do research about Lithium and how it developed, it became clear that although Cade certainly was the first person to use Lithium in mania and sparked a lot of other research, a good number of other researchers participated in the discovery. They brought important elements to it and finally established Lithium for its main effects, which are to prevent episodes of mania and depression. The book became more than just the story of one man, it became the story of the scientific process, and the scientific discovery and I tried to look at the elements that went into finally getting Lithium established.

Dr. Puder: It was interesting, and it’s a great story, because it gives us that glimpse into the scientific method, the errors of how we develop bias, and how charisma can get in the way of finding the truth. Before we launch into it [Lithium], tell me a little bit about the natural course of bipolar pre-Lithium, pre-medications. 

Dr. Brown: First of all, for untreated Bipolar, roughly 20% of people with the illness with kill themselves. Suicide is very common in manic-depressive illness, particularly during the depressive phase, so 20% of people will end up dead as a result of the illness. The illness does not go away on its own. The usual course [of Bipolar] is that the frequency of the episodes of both mania and depression increase over time. People usually start off with, let’s say one episode of mania every two years, then they’ll change to having one episode every eighteen months, and then one episode a year. These episodes are almost invariably followed or preceded by a very, very severe depression. That’s the typical course, and that was the course of the illness before John Cade made his discovery. There really was no effective treatment other than using electroconvulsive therapy to treat the depressive phase (and sometimes the manic phase), but the alleviation of symptoms didn’t last very long using electroconvulsive treatment.

Dr. Puder: How genetic is Bipolar in your estimation, and what do we know about it at this point? Specifically, I was reading about how you looked at some of the Amish Studies and I think people would love to hear about that. 

Dr. Brown: Let me say upfront: we don’t know what the genes are that underlie manic-depressive illness. But I don’t think that there’s any question at this point that it [Bipolar] is a genetically based illness. It runs in families and there are probably several genes that underlie the disorder.  How do we know that it’s genetic? Probably the family studies that have been done over the last three to four decades have been the most important. The acid test for heredity is the comparison of monozygotic and dizygotic twins and the different concordance rates for the illness for the different types of twins. Concordance means: the likelihood that if one twin has the disease, the other twin will also have it. For manic-depressive illness, the concordance rate for monozygotic twins (those who have identical genetic make-up) is about 60%, but the concordance rate in dizygotic twins (those who don’t share the same genes and come from different eggs) is closer to 10%. That tells us that genetics plays a big role and that the family environment, which is going to be roughly the same if you’re a dizygotic or monozygotic twin, plays very little role in the expression of this illness. The relatives of manic-depressive patients have a 10-20x higher prevalence of manic-depressive illness than the general population; it’s clearly genetically based.

Dr. Puder: What was it like for people [with Bipolar] prior to Lithium? How where they treated? I think it would be interesting to talk a little bit about some of the specific examples of how people were treated; like Rosemary Kennedy, the sister of John Kennedy, who had a lobotomy. When I read that in your book it just broke my heart, because it was so tragic that it had to happen. Tell me a little bit about what life was like and how these people were treated. 

Dr. Brown: People with manic-depressive illness were treated the way people with other serious mental illness were treated up until the mid-20th century. That was whatever was currently in use to treat the seriously mentally ill was used for manic-depressives. In antiquity, way back when, there really were no treatments. People were cared for by their families and kept sometimes in horrendous circumstances If somebody was depressed, they were probably left alone until they got better. Depression, even the severe depression that is part and parcel to manic-depressive illness, actually goes away in most people after a period of six month or so.  But when people were manic, it involved a lot of bizarre behavior, rapid speech, sexual excesses, and physical violence, all kinds of things that created problems for society and the family. These people were sometimes locked in prisons, they were kept in cages in their family homes; basically there was nothing useful that could be done for them. Through the middle-ages, there were various kinds of potions and things we used to treat all kinds of mental illness, including compounds that contained opium (which would sometimes sedate people but really didn’t alleviate the fundamental symptoms of the illness). 

Then in the late 19th century, a number of physical treatments started to come into play. These included malarial treatment of tertiary syphilis. People with tertiary syphilis, or neurosyphilis (which is a horrendous attack on the brain, it’s a degenerative brain disease), made up a large portion of the patients of asylums. Some of these patients had the symptoms of manic-depressive illness, though they didn’t have the classic symptoms that we later learned were characteristic. 

People were treated with malarial fever therapy, which killed the spirochete that caused the illness [syphilis] and some of those people probably had manic-depressive symptoms; that was used at the turn of the 20th century. Other treatments of the era included insulin coma, which was used to treat manic-depressives as well as schizophrenic patients. People were given doses of insulin that brought their blood sugar very low, they would go into a coma, sometimes they’d have seizures, and this went on for days. This was a very dangerous treatment that was thought to be useful in both depression and schizophrenia, but with further study, turned out not to be terribly effective; but it was widely used for a number of years. Deep sleep therapy, which was not dissimilar to insulin coma, was also used. People were given high doses of sedatives and put to sleep for weeks on end, supposedly when they awoke they would lose some of their psychotic symptoms. That didn’t last very long. 

Finally, one of the most notorious treatments, that you have already alluded to was lobotomy, which was discovered by Moniz, a Portuguese neurologist in the 1930s. This involved severing the frontal lobe from the rest of the brain using what was essentially an ice-pick stuck through the orbit of the eye. This was a treatment that supposedly was useful both for severe depression, severe obsessive-compulsive symptoms, and it was certainly used for a number of manic-depressive patients (we now call them Bipolar). It [lobotomy] was very widely used in the 1940s and early 1950s. After several decades, both psychiatrists and neurologists concluded that it was not terribly useful, that people really didn’t know what they were doing to the brain when patients had this procedure. The procedure had a lot of awful side effects including intellectual impairment and socially inappropriate behavior. That’s what happened to Rosemary Kennedy, she became essentially a vegetable as a result of it. That treatment was finally abandoned, although variants of it are sometimes used today. 

The other big change over the years was in the role of asylums. Asylums started out in the Middle Ages as being not very different from jails. In fact, the kinds of people that were sent to the Asylums of those days were both criminals and those that were mentally ill; anyone who was “troubled” in society. In the 19th century, a number of humanitarian changes were brought about in asylums. Patients were treated with what they called “moral treatment”, which meant bringing them in, not chaining them up like they had been previously, giving people good food, a chance to work in gardens and so forth, and there was a feeling that a lot of patients actually recovered as a result of being in these pleasant environments. But on closer scrutiny, it was clear that this kind of so called “moral treatment” really didn’t accomplish much and patients weren’t much better after it, so it was largely abandoned.

Dr. Puder: Why do you think poets have a higher rate of bipolar? You mentioned in your book that 20-40% of poets have bipolar. You also mentioned that writers, artists, and composers have 5-15x higher rate than the general population. What are some of your reflections on that? 

Dr. Brown: It’s clear now, from multiple studies conducted over a long period of time, that there is an association between certain types of creativity and manic-depressive illness. People, particularly poets, but also writers, composers etc. have much higher rates of manic-depressive illness than the general population. The association seems clear, but why it exists, I don’t think anybody really knows. There’s all kinds of speculation that the gene that puts people at risk for manic depressive illness many also separately have something to do with creativity. In fact, family members of people with manic-depressive illness, who don’t have the illness themselves, often score high on measures of creativity. So it seems like there might be some genetic connection between manic depressive illness and creativity. 

It’s also been speculated that the experience of having these very intense moods somehow facilitates the poetic imagination and is somehow related to a person’s ability to perceive the world around them in the kind of special way that poets do so. But nobody really knows for sure what underlies this association.

Dr. Puder: Tell me about the story of John Cade—some of the highlights, and some of the things that were like “ah ha!” moments for you. 

Dr. Brown: One kind of perception of what Cade did is that he was just was lucky; he just sort of stumbled on something and he really didn’t put much thought into it. I think the story is more complicated than that. First of all, he was born into a family where the father was a psychiatrist. His father, when Cade was quite young, joined the Australian expeditionary force to fight in the First World War. He was overseas for a number of years, assigned to an ambulance corp that was like a mobile hospital. When he returned from the World War, the senior Cade was in rough shape; he was not the person he was before he left, he was shattered psychologically. He was unable to work effectively as the general practitioner that he was before the war. So he took a salaried position with the Victoria of Australia Mental Health Service and he became director of several mental hospitals. In those days, the director and his family lived on the grounds of mental hospitals. So John Cade grew up among severely mental ill patients and his son speculated that it gave him a special empathy with these people, a kind of comfort with them, and a desire to help them. Cade attended a very prestigious secondary school called Scotch Academy, and then went on to Melbourne University where he went to medical school. At first, when he graduated from medical school he was going to go into pediatrics, but decided to switch to psychiatry.  

At that time, psychiatry training was not as formalized as it is now, so he worked for a couple of years in various psychiatric hospitals. Then, like his father, he joined the army with the outbreak of the Second World War and he was also assigned to an ambulance division. He shipped out in 1940 to what was then called Malaya [now Malaysia] as a general medical officer in the army, he was not officially a psychiatrist. 

Then in 1941, the Japanese invaded the Malayan peninsula; the war that ensued was a complete disaster for the British and Australian commonwealth forces. Even though the commonwealth forces outnumbered the Japanese 2 to 1, the Japanese were battle hardened and had much better leadership - strategically they did a lot better. The commonwealth generals made a lot of errors. Finally, the commonwealth forces retreated to Singapore, where they made a final last stand and were defeated. About 30,000 of these soldiers were imprisoned in the Changi POW camp, which became notorious, and Cade was among them. He was imprisoned for three and a half years.  

During his imprisonment he underwent severe malnutrition, as did all of the other prisoners, which was the major problem at Changi. The Japanese had not ratified the Geneva Convention, which stated that prisoners had to be fed an adequate diet, so these guys really were grossly underfed. Cade, because of his psychiatric experience, was put in charge of a 12-person psychiatric unit and he was the only doctor there who did that. There he cared for, and did consultations for, POWs who developed psychiatric disturbance. This experience did a number of things for Cade: (1) it convinced him that the needed better treatment for things like depression and (2) a lot of mental illnesses had a biological basis. When he would do autopsies on some of the psychiatrically ill he would find various kinds of brain abnormalities, including hemorrhages and tumors. Clearly the vitamin deficiency diseases he was seeing sometimes had a psychiatric component. 

When Cade returned home, he took a job at a psychiatric hospital run by the Victorian Mental Health Service, and there he decided to start some research looking into the causes of manic-depressive illness. He theorized that, like thyroid disease, manic-depressive illness results from both an excess and a deficit of some normal bodily substance (in the case of the thyroid, thyroid hormone). He was going to look for the toxic substance in manic-depressive patients that caused the illness.  

At this point things get a little bit difficult to follow logically, but he started doing some experiments with guinea pigs where he injected the urine of manic depressive patients and basically judged the toxicity of the urine by how much it took to kill the guinea pig; by his own admission, it was a crude test of toxicity. He found that, in fact, some of the urine from manic-depressive patients seemed to be more toxic than the urine of people with other psychiatric diagnoses and health people. He then began to look for the substance in urine that could be causing the mania and in doing this he went through various constituents of urine. In the context of all of this, he began to inject the guinea pigs with uric acid and Lithium salts because Lithium was very good at bringing uric acid into solution. So he started using Lithium urate and Lithium carbonate to examine the role of uric acid in this toxic urine, and when he injected animals with these Lithium salts he found that they became somewhat tranquilized. The guinea pigs would lie on their backs placidly just looking up at him, not running around and looking startled like they usually would. This somehow gave him the idea to go next door (his laboratory was on the grounds of a psychiatric hospital) and go to the ward with a bunch of severely manic patients and see what Lithium would do for them.  

First he took Lithium in varying doses himself, because there really wasn’t much experience in the [medical] literature using Lithium at the doses he planned to use it in humans. The Lithium didn’t hurt him, although his wife was not happy about the fact that he was experimenting on himself. Then he started giving Lithium to manic patients. The first patient he gave it to had been chronically manic for about five years. Within two weeks of getting Lithium citrate this man was able to leave the ward, ultimately went home and returned a useful occupation. Cade then went on to treat an addition nine patients, all of whom did remarkably well on Lithium, better than they had on any other kind of treatment that was thrown at patients at the time. He wrote up his results in the Medical Journal of Australia, and that was the beginning. 

Dr. Puder: He [Cade] sounds like such an amazing person. I remember one of the quotes you had from one of his speeches about all the different types of science and all the unique interests he had throughout his career and he seemed like such an intelligent person. 

Dr. Brown: What struck me most about how he [Cade] operated was his capacity for unfettered neutral observation. He was very interested in the natural world and I point to several examples in the book. He was very interested in scat of animals. He did his own research on birds and looking to see if the White-backed Magpie and the Black-backed Magpie were different species or varieties of one species. He pointed out to one of his sons that the fact the Gum Emperor Caterpillar Moth produced a feces that was six-sided meant they had a six-sided anus. He was always looking at things and examining them. I think his ability to see the unexpected was somewhat unusual. He certainly didn’t expect to see the guinea pigs that he gave Lithium to to become tranquilized. I think there aren’t a lot of people who trust unexpected observations. As Yogi Berra supposedly said, “If I didn’t believe it, I wouldn’t have seen it.” But Cade believed things that he saw for the first time and I think that cognitive characteristic really facilitated his discovery. 

Dr. Puder: I want to jump ahead a little bit, for the sake of time. There’s a lot more to this story that I’ll leave for people to read about how it [Lithium] when from his discovery to not being widely adopted much later. I wanted to pick your brain a little bit on a statistic that you mentioned; that 50% of people with Bipolar in European and Scandinavian countries receive Lithium, but only 10% in the U.S. I wanted to get your opinion on that and also your thoughts on why that might be the case. 

Dr. Brown: It’s hard to get highly reliable numbers on how many people are taking Lithium because nobody is really tracking it. The pharmaceutical industry is not really interested in what’s going on with Lithium because they can’t patent it and don’t make any money from it.  The best that I could come up with after combing through the literature was this 10% vs. 50%. I think there are two reasons for that. One is that after the 1980s other drugs, particularly Depakote, came out on the market that could also prevent episodes of mania and depression; the drug company that made it promoted it very aggressively. Depakote was heavily marketed and promoted and to some extent took over Lithium’s role as the “gold standard.” The second thing is that Lithium can create serious side effects (I might say that Depakote also has side effects). In order to safely give Lithium to somebody, it has to be given along with the measurement of Lithium blood levels. The reason for this is that the Lithium blood level required for a treatment effect, or a therapeutic effect, is not very far below the Lithium level that will give somebody toxic symptoms. These include tremors and other neurological symptoms such as coma, and people can die from a Lithium overdose.

But once blood levels are monitored, which is not that hard to do, and doesn’t need to be done more than once or twice a year when someone is stable, it works perfectly well. I think the third reason is that historically, in this country, Lithium created trouble. Around 1949, Lithium Chloride, another salt of Lithium, was promoted as a salt substitute for people on low-sodium diets. Lithium Chloride tastes salty, but it doesn’t create problems with Hypertension and Kidney Disease that Sodium Chloride does. People started using it a lot and they were pouring it very liberally on their food. A number of patients, around 1949, got toxic from the use of Lithium salt substitute; some died. The FDA banned Lithium and banned its use in other substances.  People didn’t forget about that, it was a real panic. It didn’t last very long, maybe about a year, all the Lithium was taken off all the shelves in all the pharmacies. People remember that salt substitute debacle and that may have had something to do with its [Lithium’s] slow uptake in the U.S. But I think the primary reason for the fact that Lithium is somewhat underused here [the U.S.], I think is the aggressive marketing of those other drugs.

Dr. Puder: Yeah, I think that’s why I get passionate about this for my audience. There’s no drug rep that’s going to come to your office and promote Lithium. So I think that people who are looking at the science, that are looking at the data, are trying to treat patients according to evidence-based medicine  - we’ve got to keep putting those principles out there. What is your one big take away maybe about the history of Lithium or maybe about the scientific method? 

Dr. Brown: There are a couple, one is that it’s important that whatever institutions that are trying to promote innovative research keep a look out for people who are imaginative, like John Cade, are careful observers who might not necessarily be inclined to write an extensive grant proposal. Sometimes the kind of people who are likely to make important, break-through discoveries are not the kind of people that are necessarily getting funded in this country.  There’s a tremendous concern on the part of the psychiatric establishment and the research establishment over the lack of real innovation, particularly in treatment. 

After Cade’s discovery in 1949, the following decade from 1950-1960, all of the major types of drugs that we use today were discovered, the anti-depressants, antipsychotic drugs were discovered. Since that time there have been many new drugs, different drugs have come on the market, but they really don’t represent a change from those earlier drugs.  Why don’t we have more innovation? Why does the National Institute of Mental Health spend a “gazillion” dollars on all kinds of research, but as the former director of the NIMH said, “it hasn’t really moved a needle with respect to coming up with better treatments for the conditions that plague us.” I think we need to take a look at how me approach innovation. 

Dr. Puder: That makes me think. Writing grants and doing research you have to be very organized. There’s this other side of our human potential, which is people who are highly creative and often are more spontaneous, are high in openness. They’re almost like two different types of people. The kind of person who rises up in research now a days, you have to be highly organized, almost obsessive with how detail oriented you are. Does that make sense? 

Dr. Brown: Yes, absolutely. The other take away, and I think one of the things I try to convey in the book is how different scientists learn from each other. There was a sort of web of information that was created about Lithium and I document how after Cade’s discovery some other Australians looked at Lithium, then a Dane named Mogens Schou went ahead and did some very important studies, people read his papers and added some very important information…. So it [the book] is also an illustration of how scientific discoveries build on each other. 

Dr. Puder: I really appreciated that part of your book. I think it’s a great book, because it really does show the scientific method, I think it also shows the danger of different charismatic leaders who had ideas about what the best treatments were for mental illness, how they utilized their charisma and often good intentions, but were not as scientific minded and open to internal critique as some. I’ve really enjoyed our conversation. I would love to dive into some of the pivotal papers at some other time if you would like to talk about that, I think that it would be a lot of fun. 

Dr. Brown: Sure, that would be great. Thank you for such penetrating questions. 

Special thanks to Dr. Walter A. Brown for the excellent discussion about John Cade and the history of Lithium. If you would like to read more of the story, you can find Dr. Brown’s book, “Lithium: A Doctor, a Drug, and a Breakthrough” here

Is Elon Musk’s Neuralink A Science Fiction Horror Show or The Salvation of Humanity?

Is Elon Musk’s Neuralink A Science Fiction Horror Show or The Salvation of Humanity?

One of the more controversial components of the Neuralink presentation was Musk’s inclusion of his beliefs about the future of humanity and artificial intelligence. During the press release he stated one of his goals was to create the ability to achieve a “full symbiosis with artificial intelligence,” essentially removing the “existential threat of AI” which he believes will one day “leave us behind” (Neuralink, 2019). This goal has been met with a bit more skepticism, especially by the national media, than the medical applications of Neuralink’s BMI. Forbes describes it as “a bit more fantastical” than the company’s primary goal of treating brain disorders (Knapp, 2019). Other publications have been far less kind, such as The Atlantic, which published its coverage of the Neuralink press release with the title: “Elon Musk’s Next Wild Promise: If someone is going to revolutionize what it means to be human, do we want it to be a tech titan?” (Mull, 2019). Although the New York Times surmised that “one of the biggest challenges may be for his scientists to match his grand vision,” (Markoff, 2019), it serves as a good example of what most major media outlets have chosen to do: stick to the facts.

How to Pick a Good Therapist

How To Pick A Good Therapist with David Puder, M.D., Ginger Simonton, PHD, Victoria Burghart, Valerie Pooudomsak

Victoria Burghart, Valerie Pooudomsak, David Puder, M.D.

Why is finding a good therapist important? 

Some form of therapy, in combination with pharmacologic therapy, is often the most effective treatment for mental health disorders. Let’s use depression treatment as an example: according to the National Center for Health Statistics, approximately 12.7% of people over age 12 had taken antidepressants for various disorders, including depression, within the last month (NCHS Data Brief No. 283, 2017). Studies comparing antidepressants and therapy have shown they are similarly effective; some researchers conducting these studies have made sure they compare medication to therapists with experience, who also meet best practice standards. A good example of this can be found in this 2005 study conducted by DeRubeis et al

Working with a good therapist often requires fewer sessions than other therapists to see improvement; in contrast, working with a therapist you don’t connect with, or with inadequate training, may require an extended number of sessions (Okiishi et al. 2003).  People that see effective therapists are more likely to recover or partially recover, whereas those that work with a “bad” therapist are more likely to see no change or an increase in symptoms (Okiishi et al. 2006). 

How will I know if I’ve found a good therapist? 

Fortunately, Len Jennings and Thomas Skovholt, both clinical educators and licensed practicing psychologists, had the same question: What are the characteristics of an expert therapist? 

To answer this question, they asked therapists in their community to nominate those whom they felt were “master therapists,” those with considerable expertise and high rates of client success.  After extensively interviewing 10 of these “master therapists,” they found that the therapists’ beliefs about what traits are essential in a good therapist fell into three categories: 

  1. Cognitive characteristics

  2. Emotional characteristics

  3. Relational characteristics (Jennings and Skovholt 1999). (an article I highly recommend reading!)

Cognitive characteristics of good therapists

The definition of the word “cognitive” is relating to or involving conscious intellectual activity, including thinking, reading, and remembering. These characteristics relate to how the therapist approaches their work from a logical or clinical perspective. 

Good therapists have a hunger and thirst for learning. They actively seek out new information, therapeutic techniques, and opportunities to discuss their work with other therapists. They embrace the idea that “the more you know, the more aware you are of how much you don’t know,” and are never quite satisfied with their current mental resource bank. 

Good therapists grow through their rich life experiences, through their own mentors and therapists, and can utilize their experience in the service of others.  They have a variety of rich and sometimes difficult experiences through which openness and a learning mindset utilize as ways to grow. Experience as a therapist is not enough. The master therapist must be open to feedback, growth, and process life’s events to be of help to others.  

Good therapists value and thrive in the complexity and ambiguity of the human condition. They don’t settle for a simple, yet incomplete, answer. Instead, they drive into the fray without fear of difficult issues with multiple causes and multifaceted solutions. They are drawn towards ambiguity and complexity and continually open to learn and discover.

Emotional characteristics of good therapists 

In this context, “emotional” refers to how the therapist navigates their own emotions in work settings. These characteristics describe how they modulate their internal emotional experience. 

Emotional receptivity (open to feedback, self-aware, reflective, and non-defensive) is an important indicator of a good therapist. These therapists are acutely aware of their own emotions and reflect on them. They approach any feedback, especially negative feedback, with a non-defensive attitude and openness that validates their client’s feelings and concerns. Their own therapy and supervision gives them continued increased insight into their own experience and the experiences of others.

Expert therapists know how their own emotions impact their work and how they relate to their clients.  They spend time taking care of their own emotional health. Most meet or have met with their own therapist on a regular basis; they’ve put in their own work. Their home life and work life are congruent with each other (they are not two different people). They know it is important to maintain their own emotional health, and do so through exercise, therapy, mentorship, and spirituality.  

Relational characteristics of good therapists

The relational characteristics describe how the therapist interacts with their client, perceives and interprets their client’s emotions, and responds to them. These characteristics describe how the therapist connects with others. 


Good Therapists have strong social skills and excel in interpersonal communication. They have the ability to relate to others and create a safe environment for their clients. They have a clear and genuine interest in people. If you ever go to a therapist that seems uninterested or bored, either they are interested and just don’t outwardly appear to be so, or you’re seeing the wrong therapist. 


The strong relational skills and warm, caring environment created by excellent therapists is often related to their personal background. Many are from families where they developed listening and observational skills and were in a position to care for others (they were the family therapist from a young age). Others are sensitive and compassionate because of their own experiences and personal wounds. 

Good therapists focus on forming a strong therapeutic alliance and believe that the partnership between client and therapist is the source of change. They believe in their client’s ability to make changes and will to do even when it’s hard. These therapists use their relational skills to challenge their clients and keep them moving forward while providing them with a safe and supportive environment. They develop their situational judgement and use it to time their interventions. Master Therapists are not afraid of experiencing or witnessing strong emotions or being present during intense and difficult moments. 

A few more things to keep in mind… 

Sometimes you get what you pay for. Sometimes, good therapists can charge cash, and because of their reputation, they remain capable of living off what would seem like a higher feel than one might expect. A busy city attracts more therapists who do cash pay. In Santa Monica for example (where I went to the NCP for 2 years), the fee was anywhere from 150-250 for a psychotherapist per hour, and 350-600 per hour for a psychiatrist. Rates vary depending on location. I often tell patients to look at who is contracted with their insurance first. We look at the list, and consider which would be the best fit.  If they have financial means, I often encourage them to see the best therapist possible. It still surprises me that many people will pay 30k for a detox center for 1 month (or a car), but not 30k over the course of 2-3 years seeing an excellent psychotherapist. The amount of benefit that 1 year of therapy will often lead to a strong ripple effect for the rest of your life.  

Do other mental health professionals recommend them? Ask around. Mental health professionals form their own community. They work with others and are often aware of professional reputations. If your psychiatrist has been practicing in the area for a while, ask them for recommendations. If you have been seeing a therapist that you like as part of an intensive outpatient program or a community-based program, ask if they take on clients outside the program. If they don’t take on clients, ask if they know of any good therapists in the community. 

Don’t be afraid to try going to a new therapist if you don’t “mesh” well with the one you’re seeing. If you’ve been to a therapist for several sessions and you don’t feel connected or uneasy with that therapist, don’t be afraid to look for a different one. However, I recommend talking to your current therapist first about concerns you have and seeing how they respond.  If they are open and learn from it, that can be very connecting. Be up front with them about your feelings of being disconnected or uneasy and see what happens. Once your therapist is aware of your concerns they can take steps to make you feel more connected or comfortable. (**Within reason of course, therapy is NOT supposed to be a comfortable experience. If you feel relaxed the whole time, it’s time to reevaluate whether or not you’re getting anything done during therapy sessions.)

Be prepared to work hard. Once you find a good therapist they are going to push you out of your comfort zone. They’re in it for the long haul to work with you through the issues that you’ve been avoiding. Remember, we avoid things that make us hurt for a reason, but sometimes the best way out is through. 


Finding the right therapist can be difficulty and challenging.  I hope that from reading and listening to this episode you can find the right fit for you. I also highly recommend reading Len Jennings and Thomas Skovholt’s article found in the resource library: here

Suicide Epidemiology, Risk Factors, and Treatments

On this week’s episode of the podcast, I interview Jaeger Ackerman, 4th year medical student about suicide risk factors and treatments.

Jaeger Ackerman, David Puder, MD

Treatment for Suicidal Patients

As a therapist, attempt to closely approximate their reality of feeling suicidal with words.  When I first hear their thoughts and feelings, I try to clarify with the patient to make sure I’m understanding their feelings. I usually try to put it into other words, and echo back to them. I’ll say something like, “I hear that you feel like there’s no other way out, that you feel lost and like it’s a very dark time for you.”  I ask myself continually how to be present with them in their feelings, in the moment.

I often hear therapists say that they feel uncomfortable putting it so strongly, and try to soften their response to their patients. In reality, a patient feeling heard and understood can meet them where they are, rather than making them feel like they are being agreed with. It creates an empathic connection, which, in turn, can make a difference. 

I also try to give them a little bit of hope. I tell them we haven’t exhausted all of the opportunities to feel better, and that I will be with them through it. 

I’ve seen people at their darkest times come back from deep depression or trauma and suicidal thoughts and return to a healthy life. But that takes time. And we won’t have time if they commit suicide. Statistics and numbers sometimes can distance us from the person who is struggling with suicide. However, I think it is important to identify populations at risk, and to use science to help those the most people we can.  

The Epidemiology of Suicide

In the United States, suicide is the 10th most common cause of death in adults, and the 2nd leading cause of death for persons age 15-24. Nearly 1.7% of deaths in the US general population are because of suicide, and there are over 45,000 suicides per year (Drapeau and McIntosh 2016). Rates are higher in the western states and lowest in the mid-atlantic states. Internationally, rates are highest in eastern European countries like Scandinavia and Hungary, and are lower in countries with large Catholic or Muslim populations. The highest rates of suicide peak in late spring, with a smaller secondary peak in the fall. Economic factors tend to influence suicide rates as well, with some of the greatest rates seen during the Great Depression (Mann, Apter et al. 2005, Yip, Caine et al. 2012, Black and Andreasen 2014).

General Risk Factors in Suicide: SAD PERSONS

The SAD PERSONS mnemonic is a helpful way to remember some of the most significant risk factors for suicide (Patterson, Dohn et al. 1983). 

This stands for:

Sex: Males are 4x more successful at completing suicide, while women attempt 3x more often

Age: a bimodal distribution with greatest rates between age 15-24 and in males older than 75

Depression: rates are 20x greater in depression than in the general population

Prior History: 80% of completed attempts are preceded by prior attempts

Ethanol abuse: substance abuse in general is associated with a 2.5x greater suicide rate

Rational thinking loss: cognitive impairment secondary to intoxication, delirium, or decreased sensorium may increase impulsivity and decrease inhibitions which increases suicide risk

Support System loss: including divorce, widowers, deaths of relatives, and isolation in general

Organized plan: those with a methodical plan are at greater risk of completing suicide 

No significant other: spouses, parents, and children serve as protective factors against suicide

Sickness: about 5% of suicide completers have serious physical illness at the time of suicide 

As a caveat, access to firearms should also be considered a significant risk factor for suicide. More than half of completed suicide in the US are completed using firearms (Miller and Hemenway 2008). 

Mental Illness and Suicide

90% of suicide completers had a major psychiatric disorder diagnosed at the time of suicide, and over 50% are clinically depressed (Black and Andreasen 2014). With regards to Major Depression Disorder (MDD), 10-15% of patients who are hospitalized for depression will go on to commit suicide. MDD may be further characterized as melancholic, catatonic, with anxious distress, or atypical features and each has a unique association with suicide risk to be familiar with. Melancholic depression is more common in the inpatient setting and predicts a good response to antidepressants or ECT. 

Catatonic depression has potential risk for malnutrition, exhaustion, and self-harm as many of these individuals lose the drive to eat or drink entirely. One study found a 60-fold increased risk of premature death, including suicide, in adolescents with catatonia (Cornic, Consoli et al. 2009). 

Anxious distress is associated with higher suicide risk, longer duration of illness, and greater likelihood of treatment noresponse. Anxiety sensitivity, or the fear of anxiety related symptoms, has been associated with a small-to-moderate increase in suicidal ideation and suicide risk (Stanley, Boffa et al. 2018).

Bipolar Disorder has even higher rates of suicide than MDD with 29.2% attempting suicide and 4.78% completing suicide (Baldessarini, Tondo et al. 2019). Risk for suicide is high both in the manic state and in the post-manic or depressive state when the individual becomes remorsefully aware of inappropriate behavior that occurred during the manic episode. In general, patients with bipolar type 2 have higher levels of suicidal ideation, however, bipolar type 1 is associated with a greater number of attempts.

Schizophrenia has a high suicide comorbidity. Up to 50% of schizophrenics will attempt suicide and 10% will commit suicide. Those at highest risk are unemployed males under 30 with chronic disease course and history of depression or substance abuse. Interestingly, akathisia is an independent risk factor for suicide. Akathisia is a sensation of both internal and external restlessness that may occur as a side effect of antipsychotic medications used to treat schizophrenia (Drake and Ehrlich 1985).

OCD is associated with a suicide rate of 14.25% and suicidal ideation is seen in 44% of individuals with OCD (Albert, De Ronchi et al. 2018). 

Borderline personality disorder is the most frequent personality disorder and is diagnosed in 15-50% of psychiatric inpatients. Suicide rates are between 5-10% and the majority of borderline patients will attempt suicide multiple times. Self mutilating behavior, which occurs in 50-80% of borderline personality disorder is associated with about a 2x greater suicide rate than in borderlines without self-harm behavior (Oumaya, Friedman et al. 2008).

There is a significant positive relationship between primary psychopathy and history of suicide attempts (Verona, Patrick et al. 2001). The DSM5 goes out of its way to state that individuals with Antisocial Personality Disorder (ASPD) are more likely than members of the general population to die by violent means. The suicide rate in ASPD is close to 5% and the attempt rate is 11% (Frances, Fyer et al. 1986).

Substance Use and Suicide

The lifetime risk of sucidie attempts in alcohol dependence is estimated at 7% (Inskip, Harris et al. 1998), while any substance use disorder is associated with a 2.47x greater risk of completed suicide (Ilgen, Bohnert et al. 2010). Current substance use disorders signal increased suicide risk, epsecially among women, and may be important markers to consdier inclduing in suicide risk assesment strategies (Bohnert, Ilgen et al. 2017). 

Evidence from a large-scale study in Quebec shows that the acute phase prior to entering treatment programs for addiction is a particularly high risk timeframe. Rates up to 33.3% for ideation and 5.7% for suicidal attempts was observed in patients within 30 days of entering treatment (Simoneau, Menard et al. 2017). 

Data from the Veterans Health Administration informs us of the specifc hazard ratios for indiviudal substacne use and risk of suicide. This study found that the overall rate of suicide was 75.6/100,000 indiviudals in veterans with any substance use disorder, as comapred to 11/100,000 in the general population. Females were found to be especially susceptible to an increased risk, and opiates (8.19) or sedative hypnotics (11.36) had the greatest hazard ratios (Bohnert, Ilgen et al. 2017).

Substance use in physicians should also be addressed in assocaition with suicide. In one large-scale study, 27% of all physician suicides had one or more illicit drugs detected at autopsy or had a blood alcohol level greater than 0.8%. Physicians were at significantly higher odds of having antipsychotics, benzodiazepines, or barbiturates present on toxicology testing (Gold, Sen et al. 2013). This begs the question of whether or not these drugs were ingested for therapeutic or toxic purposes prior to the suicide. Evidence from this previous study is in line with other studies demonstrating a higher risk of poisoning or overdose deaths among physicians, presumably due to easier access to these drugs (Hawton, Clements et al. 2000).

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