Psychiatry & Psychotherapy Podcast - Genetics and Environmental Factors in Suicide

Episode Date: September 19, 2019

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.   By listening to this episode, you can earn 0.75 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is emailed to you in seconds. Before we start this episode in which I have a conversation with Jagger Ackerman, a fourth-year medical student, I wanted to talk a little bit about what we are going to talk about and the importance of this topic. You know, we are in a month of suicide awareness right now. And in my own life, there was a local church pastor, a megachurch pastor, and he was an assistant pastor to this, to harvest.

and he committed suicide recently. And so on social media, I don't know if you were aware, but there are people coming out and having opinions about, you know, why did they allow a pastor who had mental illness to be a pastor? And in my mind, a lot of the words that were coming out about this are very stigmatizing to mental illness and to the struggle that people face. And so suicide is something that, you know, I see frequently, I see in the patients that come in who have had family members who have committed suicide,

I see my patients themselves struggle with suicidal thoughts or they come to see me after they've had a significant suicide attempt. And so I think as we go through this series, and this is part two, and we're going to be looking at the genetics and the environmental factors that influence the risk of suicide or predisposed people to have suicidal thoughts. As we think about these things, it's really important to think about how families have been devastated by family members who have committed suicide and the support and the empathy that we need to give these people

and how careful we need to think about the words that we use. How do we empathize with someone's distress? How do we be present with someone in the midst of their suffering? Whether it's an ongoing struggle that they've had with suicidal thoughts or with ongoing struggles that they've had in their family. More than anything in this series, I want to give hope. Hope for providers that providers can learn more about suicide and become experts and feel confident in treating these complex issues.

right. And then also empathy for patients and for family members who might be listening to this wondering about suicide and how it happened and how things got there. And, you know, thinking about their distress as well and thinking about how it might be to have a conversation about this. Specifically with this one instance in Riverside, California, at Harvest Church, and thinking about that case, you know, this was this was a pastor who had a real commitment to help people with mental illness. He started a whole whole project at their church helping these people. And, you know, I think people who are in the front lines helping people have unique stresses. You know, I think physicians and therapists who are on the front lines of taking care of the mentally ill,

they feel that affect. It takes me back to when I was first starting my training in psychiatry as a third year. And it was so difficult for me to be in the inpatient setting, to be with people who were acutely suicidal. And I took that on and I would go home and I would feel depressed and I would have to work through these feelings and these emotions. And it would trigger things from my past that I had not worked through.

And so, you know, I think having compassion for ourselves as providers that, yes, we need breaks, we need weeks of vacation, we need times of rejuvenation, we may need to do our own therapy. You know, and so thinking about some of these comments online just blow me away that, like, you know, it would exclude you from doing ministry if you had mental illness. That is so far from the way that I see it. I see that like people struggle and, you know, more than half of Americans at some point in their life will have some sort of mental illness. And, you know, some people, it will just be for a couple months and they'll snap out of it and never have it again. But other people, it will be more chronic. And I think struggling with mental illness allows you to understand what it means to be human, you know. and that we all have some weak part of our body

that will get broken down first. Some people, you know, it's headaches. And the first thing that happens when they have chronic stress is they get chronic migraines or chronic tension headaches. Some people, it's irritable bowel or gurd or more like stomach issues. And some people, the first thing that they experience is depression. And we should have compassion for people who struggle with mood issues, just like we would have compassion.

for someone who struggled with any other physical issue. So that's my little intro. And now what to expect from this session? Well, we talked a lot about genetics in this episode, and we talk a little bit about environment and how those can increase the risk of suicide. And as I got to the end of this discussion, I think one of the main takeaways I had

was that really beyond genetics, beyond environmental factors, choice is that third factor. And so in the subsequent episode that follows this one, we're really going to talk about choice a lot and how choice can impact our progression in mental illness. And it's not something that we like to talk about as much because it's harder to put research around, because there's so many factors that come into play.

You know, I came to the end of this research and digging into genetics and the environment. And I realized that, you know, on average, the suicide rate is around 10 per 100,000 people years. You know, so 1% of the population will die by suicide. And if you look at monozygotic twin studies, in the largest study, only 4% of the monozygotic twins, if one twin, the other one would commit suicide. So it was 2% for dyzegotic twins. 6% for monazegotic twins, that's a 2% difference.

So it's not entirely genetic. And if you look at the absolute risk increase for the environmental factors, so we know that certain environmental factors and we'll go into the details and increase the risk around four times what it would be otherwise to commit suicide. But if you think about 10 per 100,000 people years,

that only goes from 10 per 100,000 people years to 40 per 100,000 people years. So it increased the risk, but not like incredibly. And so I think that it's hard to think about all of the reasons that lead to someone committing suicide. But one thing that I would not want you to take away from this talk is that you are predestined to commit suicide

if you have the genes and if you have the environmental stuff. That's just not what the evidence shows. So the absolute risk is actually not a huge amount bigger. which leaves a lot a room for choice. And, you know, I've talked about this before in my Sensorian, my last Sensorian podcast. But if you were in a study where they had you read something that basically made you think that, you know, you didn't really have a choice in anything. And you were just a bunch of biological stuff going off. And, you know, you were predetermined to do certain things.

you would actually then be more likely to cheat, more likely to conform to social norms, you would have reduced helping behavior and increased aggression. And you wouldn't slow down after you made an error to reevaluate. And that last point actually is very important because that's a frontal lobe function that would decrease from believing that you have no choice. and so as we work with clients and as we work in our own mind when we have our own depressive thoughts you know realizing that there is a place of of choice now sometimes the only choice that we have is to change our environment and so to not get too far ahead but in the subsequent episode that

comes after this i'm going to be diving into the importance of psychotherapy medication management even things like TMS, ECT, ketamine, partial and day treatment programs, exercise, diet, optimizing sensorium, decreasing anxiety, decreasing aceshesia, if you have it, or getting rid of it all together, optimizing sleep and treating substance use issues, taking away guns. And all of those things are things that you can choose to do, right? So some people say, oh, don't be depressed, just snap out of it, right? That's not really the choice that we have when I think about choices. I think sometimes the choice that we have is to change our environment, to put ourselves in a

situation that would actually lead to us moving forward and growing. And so that's a little bit of a hint at what is to come. And I hope that you enjoy some of the science that's going to be laid out here with me and Jagger Ackerman. And I hope it's helpful to understanding suicide, to understand. some of the nuance and the complexity of this. And I hope more than anything that this conversation about suicide can increase our empathy for those who struggle, for our own maybe tendencies to struggle at times,

and for equipping the next generation as well on how to have increased ability to connect with people who struggle. All right, so here we go. All right, welcome back to the podcast. I am joined today with Jagger Ackerman, a fourth-year medical student who has been on a rotation with me doing some digging into suicide. And this will be part two of our sort of series on suicide. Last time we went over the epidemiology, the different main diagnostic categories that

have higher rates of suicide and some of the details on how to identify if someone is suicidal. today we will be jumping into the genetics of suicide. Welcome to the podcast. Great. Thanks for having me back on. So one of the things that I wanted to sort of jump into is how genetic suicide is. And what I mean by that is how does it run in families? How much of it has to do with, you know, heredity versus the environment. And so let's go through some of those studies.

So one of the biggest studies we looked at was the Swedish National Registry. This registry included close to 84,000 pro bands. Additionally, it showed a twin and adoption study as part of that overall cohort. The study suggested a heritability of suicidal behavior between 30 and 50 percent, and specifically they noted that when they corrected for transmission of psychiatric disorders, that the heritability of suicide in particular was between 17 and 30 percent. 36%. Yes, this is really nice, large study, like 83,000 people, almost 84,000. And that's helpful. What do they find about the offspring of the group that attempted suicide? So if they had like a

family member that attempted suicide? Right. So here, if there was an individual who attempted suicide in their lifetime but didn't complete it and they went on to have children those children themselves were five times more likely to attempt suicide in their lifetime yeah so there is a genetic link and we're going to be diving into um some of the genes some of the ideas it's it's you know 30 to 50 percent so it's not all genetics there's an environmental factor there's a choice you know, that's part of it. Let's look at the twin studies in particular versus the non-twins, because I think that gives us some information.

This part of the study is really interesting. Again, this is from the same cohort of that Swedish twin registry. They looked at the difference between monozygotic twins and dizigotic twins. The difference here being monozygotic twins would share all of the genetic information because they came from the same sperm and egg, whereas dizigotic twins, don't share exactly the same genetic information. I think it's also important to note that even if they're monozygotic, they may not express the same genes because environment does affect genes,

and that's called epigenetics. Right, and we'll talk about epigenetics a little bit later. Specifically, the difference that they found between monozygotic and diszigotic rates, though, was in the Swedish twin registry, there was a concordance rate of 0.06. monozygotic twins, meaning if one twin attempted suicide, the concordance rate was 0.06 for the other twin also attempting. So 6%. 6% of twins of monozygotic twins would both attempt suicide compared to 2% for dizigotic twins. So essentially a three times greater risk for monosigotic twins than diezygotic twins.

And the implication here is that this is likely due to the greater sharing of genetic information. And the Danish twin registry had a higher percentage, but it wasn't as large. Right. The Danish twin registry showed a concordance rate of 0.35 for monozygotic twins and 0 for dezygotic. So here you're seeing a much greater difference in rate, but, the switch twin registry is a little bit more valid of a study to look at just because it's larger. Yeah, so I would go with the 6%.

So if your identical twin tried to attempt suicide, there would be like a 6% chance that the other identical twin would attempt at some point. That's what we're seeing from this study. Yeah, and that shows that there is some genetic link in this. And so how we, you know, when we greet patients, when we, um, take their history, taking the history of a family history of suicide has a small influence on if they will also commit suicide. Okay, so I think another way of looking at genetic things is to look at adoption studies, right? So we know that if you have, for example, monosagotic twins and you separate them and you put

them in different environments or you have, you know, a parent who committed suicide, but at birth, you take the child out of that family and put them into another family, you know, this may change the percentage or the risk that that individual has of having suicidal thoughts. So when we look at adoption studies, we're curious how much it's the genes or how much it's the environment. And it's a way for us to sort of discern what's what. So in this one study of the Swedish National Registry, what do they find? This study again is a large stale study involving two and a half million individuals and over 27,000 adoptees.

They found that suicide and biological parents had similar effects on offspring suicide rates in both the non-adopted and the adopted individual. So whether or not the child was placed in a different home or continued to live in the same home as the biological parents who attempted suicide, those child rates would be similar. So the conclusion of this study was that the main familial effects of parental suicide on offspring suicide rates are not mediated by the postnatal environment primarily, but rather primarily driven by genetic similarity. With the caveat, though, that if the biological parents' alcohol abuse was a risk factor for suicide, then they actually had to grow up in the biological parents with the alcoholic parents in the home, right? That would increase the risk. Right. And that was a little bit of a almost a side component of the study where they noted that

parents with alcohol, abuse, and other drug use, if the child continued to live and be raised in that environment, that was certainly an exposure that they were raised to, that they were raised to live in that did have an outcome on suicide rates in the future. Yeah. And I think that's important

because a lot of people commit suicide are due so under the influence. and so if the parents of the child had alcoholism, then the alcoholism is a risk factor that increases the risk of many mood issues in the kids later on. Okay, so that study shows that if the parents have suicidal tendencies, even if the kids are moved out of that home, the kids will suffer some increased risk of having suicidal tendencies as well.

Absolutely. So there's, once again, there's a genetic component to this. It's not completely genetic. Remember, going back to the earlier studies, it's like, you know, 30 to 40 percent. And some of that we might add would be, in my mind, the womb environment. You know, when we look at monosagotic twin studies, like about 10% of the similarity might just do to being raised in that womb for nine months together and all the different stressors on the womb that might happen during those nine months might create similarities

in the in the in the child so is it just one gene or what have the gene studies shown there's been a shift toward looking at genome-wide association studies to actually try to figure out, you know, what genes are involved in suicidality. Is there one that is a main contributing factor? There's some that have shown statistical significance and functional plausibility, but overall it's been a little bit elusive. There's two genes that we want to mention that are potentially interesting for the future and will continue to be looked into, but there's nothing concrete yet. Those are BDNF, which stands for brain-derived neurotropic factor. And the second one is NTRK2.

And this is a receptor. It's a tyrosine kinase. That's a receptor for brain-derived neurotropic factor. Yeah, so in this one study, it showed that like over 200 genes have been associated with suicide attempts or suicidal death. And so a lot of times when people say, oh, there's no biological markers for mental illness, it's incredibly black and white or monolithic thought process in my mind. mind and it makes me think that they haven't read very much about this stuff because it's not

that there isn't biological markers. It's just that there's so many different things that can influence this. You're looking at 200 genes. We don't think in terms of 200 things usually. We think of like three things. So they've looked at many different genes and we also want to think also about epigenetics as well. So epigenetics is DNA methylation, histone modifications, so the DNA can coil or uncoil and express different things. One good example of this was a study by Dean Ornish on lifestyle change, and he showed that exercise and diet change could literally change

hundreds, if not thousands of gene expression throughout our cells. and so the choices that we make change what's going to be expressed and what's not going to be expressed. And when it comes to suicide in particular, when we're talking about this DNA methylation and histone modification, in suicide in particular, there's been an association with widespread changes in methylation patterns of neurotrophic and neuroprotective factors in the hippocampus and prefrontal cortex. and this was noted in a study by Labonte in 2013 and corroborated by a further study by Schneider in 2015. So what this really means is that, you know, the people might not be born with issues in these neurotrophic or neuroprotective factors. But for various reasons, the genes that would normally help the person have their brain produce things that,

make the brain grow, you know, make the brain modify itself, for whatever reason, they get shut down, right? And we know a lot of different mental illnesses shut down the production of brain-derived neurotrophic factor. And some of the treatments that we give actually increase brain-derived nootroph factor. And I was just looking actually, as we did a recent episode on diet and mood. And there have been studies that showed that different diets can increase brain drive nootroph effectors. So we know that we can make changes, both medication, psychotherapy, and what we eat, and I would add exercise and sleep. We can make changes that increase things that will allow our brain to thrive. And so although

we're talking a lot about genetics, I also want to add a very hopeful component here that people that I see even with like really scary genetic background, like they had a mother that committed suicide, they had a father with schizophrenia, with the right treatment, they can get better. They can get better. And I've seen people who I initially had lower hope for get better, after going through partial programs, after getting on medications. I recently had a patient who became upset because I kept recommending a partial program. It's like a day treatment program. you go from like nine to five, eight hours a day, five days a week. And if you're a provider out there, you probably had a very similar experience.

You're trying to get the patients the treatment that they need. And this person got was getting upset because I was making this recommendation. And the reason why I was making this recommendation was because I really believed that this would create the potential for the outcome that we were looking for. You know, I don't want people to just stay suicidal for years. if you've been suicidal for years, like seek the treatment that you need, like invest everything into that. You know, people will take out loans

to go through college, but how much more important is good mental health treatment, you know? So like utilize all the resources at your disposal to get the mental health treatment that you need because it's going to change your trajectory. So yeah, okay, there's my side rant. But, you know, as providers,

we need to think, what is the treatment necessary for this person to change their outcome? And I don't want to become complicit in a treatment plan, which I have seen that will not work. Okay. So I continue to try to listen to what my patient's goals are and to help them understand what might help them accomplish their goals. So tell me about chromosome two

and what they found from the genetic tendency and the family linkage of suicide, there's a possibility that we might be getting closer to a clearer genetic answer related to chromosome two. There have been some family linkage studies that have done providing evidence for a genetic tendency linked to this area. The largest and most recent study was collected from 417 subjects spanning over 162 families, diagnosed with schizoaffective disorder, bipolar disorder 1, or bipolar disorder 2. family members from this cohort with the history of attempted suicide all showed a higher degree of genetic similarity specifically at this area of chromosome 2 called 2p12. This is still a very broad area of chromosome 2 and doesn't isolate to just one specific gene, but there are several genes within this region that will prove interesting to look at.

And the same marker was implicated in a 2004 Pittsburgh study looking at suicide. attempts in major depression. Right. So there have been two previous studies looking at attempted suicide in pedigrees with alcohol dependence and also in pedigrees with recurrent early onset depression. So between these three studies, they all provide compelling evidence for a locust influencing attempted suicide at this region of 2p12. The word pedigree might be a little bit dehumanizing. You know, I mean, I think, but we are looking at patterns, right? And as providers, we want to understand what types of risk factors this person might have and what types of genetic loading they might have

that might make treatment more difficult or might help them respond to certain types of treatment. So think about this episode in the context of, you know, how we can sort of understand people when they come in and what their background is. Okay, so let's jump into low levels of CSF, F5HIAA, which is a serotonin breakdown product. So what have they found with people with low levels of that?

Okay, so these next couple components that we're going to be talking about, it's really just a grab bag of different things that have been noticed, both in severe depression. So it may indicate depression rather than a risk for suicide per se, but they have noted that low levels of 5-H-IAA, which as you mentioned is a serotonin breakdown product, there have been low levels seen in the CSF of patients who have committed suicide, along with individuals with impulsive violent behavior. And the implication here is that low levels of that breakdown product may be strongly correlated with patients with higher impulsive behavior.

Yeah, and I think, you know, there was this. big serotonin theory of depression, right? That you have too little serotonin in your brain, and that's why you're depressed. We know that that is not true, and it's an oversimplified way of explaining things. You have low serotonin, you need more serotonin. That's really not how antidepressants work long term. They actually change the epigenetics of the cells that have the serotonin receptors on them. But we do also know, like in these studies, that there were some people, who were, you know, after they committed suicide, they had lower CSF serotonin breakdown products. What else have they found in people who committed suicide?

It's also been noted that there's abnormal dexamethosone suppression, suggesting HPA-A-access hyperactivity. That's a hypothalamus pituitary adrenals. Typically, when you administer dexamethosone to your average individual, you'll see a blunted adrenal response. However, in these patients who have attempted suicide or committed suicide, they have an abnormal response where there is no blunting. So they keep producing cortisol? They keep producing cortisol even with a dexomethosone that would typically cause a suppression. Yeah, and those people are the ones without the trauma. If you have a person with a childhood history of trauma, they usually actually have a hypoactive cortisol response.

So it's hyperactive in the dexymethazone suppression test for people with just like a later life depression. It's hyperactive with it if they have early childhood trauma. And then going along with this HPA axis hyperactivity theory, it's been noted that there's high levels of urinary metabolites of cortisol and also enlarged adrenal glands that have been identified in these individuals, suggesting that the adrenals are overactive, constantly. producing cortisol. And so that's been noted again in patients with severe depression, who have also attempted suicide. Yeah. And what about BDNF? So BDNF, brain drive neurotrophactor, it's like miracle growth for the brain. What have they found in particular with BDNF in this population? So BDNF is a really interesting gene to look at. This gene regulates neuronal survival, plasticity, and synaptic function. We know that it's regulated by stress. So there's some

with that epigenetic regulation going on that we talked about as far as methylation and acetylation. There is a polymorphism in the gene. It's BDNF Val 66 Met, so essentially at the 66 amino acid, there's a change. And this has been identified in higher levels in major depression and suicide. Yeah, and lower BDNF levels in the anteriority. Singulate are seen in patients who have committed suicide outside of the genetic stuff going on. Right. So this could be this could be both epigenetic and it could be the genetic. Right. So when you're looking at the met allele in particular, that's the polymorphism.

It's been associated with an increased risk for depression. But at the same time, as you had just said, lower levels of BDNF in general have been identified in the anterior cingulate, and that has nothing to do with that polymorphism. So interestingly, though, as we looked further, in another study that was prior to this, they showed that there was no significant relationship between this VAL-66 met polymorphism and suicidal behavior. How do you make sense of that,

the sort of the mixed data on this? So that study that you just referenced, was a 2017 study by Gonzales Castro and Salas Magana. They had a large cohort. When they did break it down by ethnicity, they found statistical significance in Caucasians and Asians. However, again, this kind of gets to the complex nature of genetics, of, you know, this polymorphism may or may not be associated with suicidal behavior

depending on what studies you're looking at. But the level of the, the protein, identified that the gene encodes for. Lower levels of that have been identified in the anterior cingulate in those who have committed suicide. And so it's that complex interplay of genetics that you have that are hardwired, how they're expressed throughout the body, whether through methylation, acetylation, and then the actual levels of the protein that are found.

Yeah. And once again, BDNF can be changed, right? So this is something that we can epigenetically change. if people exercise if they eat diets that are more Mediterranean or high in nuts that's shown some change if if people go to psychotherapy or get on the medications there's a lot of medications that help increase BNF okay so I want to jump into a little bit on how environment influences suicidality so what let's go through some of the risk factors for increased risk of suicide attempts and suicidal, like, thoughts.

So one of the big studies that really helped inform us in this area was this epidemiological study in Australia, looking at 6,000 twins. They were able to identify a number of different stressors, life events, traumas that all contributed highly to a risk for suicidal ideation or suicide attempts in the future. So this included like a history of childhood sexual abuse, which increased the risk of suicidality by about four times, increased the risk of suicide attempts, by increased the odds ratio like 7.4. So that was that was quite significant. And of course we've seen this, right? We've seen this in clinical practice, people who have a history of childhood sexual abuse.

when they hit their adolescence, or even earlier than that, they can get suicidal. And, you know, as people who treat these patients, we may not always hear the history of childhood sexual abuse, but we see the suicidality. We see this like, they're just really distraught, having a difficult time. There's something going on wrong in the system, you know?

What are some of the other risk factors? being currently separated or divorced, and then specifically in females looking at female cases of rape or physical assault, both being associated with the odds ratio of about 3.6, experiencing serious accident. This was associated with a two-time risk in females, and loss of pregnancy was associated with a 1.5-time risk. So again, these are looking at traumatic life events that are happening to individuals. Yeah, and it's hard. These things are hard things that people go through that we sit with them and we feel with them into their situation. And I think this comes back to like the humanism that we need to have as we connect with people who are suffering. you know, fellow human travelers who are going through things,

just like we've gone through things, maybe worse than us, maybe different than us. But the compassion, the connection that we can bring to people in this changes the outcome. You know, therapeutic alliance changes the outcome of the treatment, both for psychiatry and just psychotherapy. And so when we think about, you know, risk factors genetically, I think it's also really important to think about, like,

the environment, sort of the whole picture and what's brought this person in today that's led them to be suicidal. We also talked about other types of environmental factors that lead to increased suicidality. Yeah, and this is an area where there's, there'd be so many things you could talk about. Adverse childhood events is a big area, attachment patterns. Incarceration is one that we were actually able to find a little bit about, There was a study that showed that recently released prisoners are at greater risk of suicide than the general population. The studies found that 156 per 100,000 person years, within the first year after release, committed suicide.

Of that, 20% of these suicides were actually within the first 28 days of release. And that's similar to rates that have been seen in recently discharged psychiatric patients. So that first year out of release from prison, and particularly in that first month, there's some very high rates of suicide and people who have been incarcerated. Yeah. And you can think about all the difficulties that people getting out of jail have. They don't have some of the support system they had when they came in. They may not have the insurance that they need to get the treatment. They may have gotten some treatment in the jail system, but they may have gotten some treatment in the jail system,

but they may not be able to connect with outpatient providers or want to continue treatment when they get out. So there's a lot of risk factors there. Plus also bad things happen when you're incarcerated in jail. The rate of rape is actually really high and just bad things that can happen in jail. And so those are like unprocessed traumas. And sometimes it's harder to seek treatment,

maybe for those types of things because of the shame that might keep people from express, what happened. So coming to the end here of this particular episode, you know, we talked about genetics, we talked about the environment. And in the future episode, I really want to go into a lot of what has to do

with like the choice, right? A lot of times we don't talk about that we can change our environment. I'm a fan that we have some free will. We always have some ability to choose our environment to make choices. and studies actually that show that, you know, studies where people were reading things where they came to the conclusion that they had no free will actually led to increased lying,

increased going with a group rather than individual thought. It led to brain waves that had looked like there were some decreased function in the frontal lobe and how they responded to quizzes and questions. and so believing in a sense that you have some choice, that you have internal locus of control, right? Internal locus of control rather than external. So I believe I can change my outcome rather than I believe the environment,

my genes are just attacking me and I can't do anything about it. And so if anything, I hope that you come away from this seeing that, yes, there is some genetic linkage, yes, there is some environmental factors. however there's treatment choices that we can do that can help our brain respond differently to the environment that can help us grow and like I said I've I had someone emailed me the other day what I thought about palliative psychiatry like basically like this person wants to commit

suicide and we're going to help them or this person's so so mentally ill that we're going to allow them to take their life you know and And I responded back, I don't think anyone is unhelpable. I think that people can get treatment that helps them. I mean, there's good studies that have eight years follow through where people who were in and out of psychiatric hospitals with severe suicidality are now on like one third of the medications and are no longer meeting criteria for a lot of the diseases that they had before.

and it had a lot to do with the years of psychotherapy. So in the next episode, we're going to be going into the treatment for suicidality, and we're going to be doing a deep dive. We're going to talk about how antidepressants can decrease brain-drivenotrovotrophactor sometimes, how lithium, clozapine reduces suicide. We're going to talk about aceshesia and how one of the things that we can change often is to get people out of aceshesia, which increases suicidality. And we're going to talk about how to optimize the sensorium.

It's something I've talked about before in three episodes. And it's something that's really important that we can change. We can change how alive or total brain function is going on in this person. And we'll also talk about how we can improve people's sleep. If we can get people sleeping, if we can get them into that REM sleep, sleep, we can help them move out of getting stuck, right? So one of the things is sometimes short-term medications to help people sleep. Sometimes treating their sleep apnea can be important, so we'll go into that. We'll talk about substance abuse and how sometimes that's the big

issue, right? A lot of what we see on autopsy is that people are using substances. That's kind of the final common pathway, I think, towards moving away from mental health. One of the final common pathways is everyone gets depressed or anxious or, you know, suicidal. Another thing is that people tend to start using substances that are there as kind of a bad band-aid. We'll talk about some of the treatment programs that have been shown to be helpful, you know, like, you know, there's three treatments for for borderline personality disorder that have been shown to be really helpful. Transference focus therapy, dialectical behavioral therapy, and mentalization-based therapy. And so we'll go into those and we'll go into some of the studies and what they've shown.

And for me, it's really, really hopeful to see those studies because it reminds me of the big picture. You know, sometimes we see patients at their worst, especially if you're a student, you're going to be seeing the patients at their worst when they're in a psychiatric hospital. But know that your connection with them, even if it's for an hour, even if it's for, you know, a week you're spending 15 minutes with them a day, sometimes that connection can be something that they tell me about years later as something that was in. important. I've had, I've had students that I've worked with and, and they'll see patients in the

inpatient and the patient will come back to me as an outpatient, you know, I mostly work outpatient. And the patient will share with me how meaningful it was to feel heard and to feel understood, even if it was for brief moments when they were at their worst, you know. So we're going to talk about, we're going to talk about the different treatment programs that have been helpful. We'll talk about therapeutic alliance and how important therapeutic alliance is. And we'll also talk about things that we can do to reduce suicide risk, like, for example, taking away guns from individuals who have a risk of suicide. You know, in America, men are much more lethal, meaning they kill themselves more frequently than women, one of the main causes of death,

or one of the main, you know, people kill themselves. but they use guns to do it. And so it's one thing that we can do to reduce the risk of suicide in that population. So we'll dive into all of these things. I also want to touch on exercise a little bit because it does increase brain drive, nootrophic factor. It does reduce the risk of future episodes of depression.

In one study, a Duke study, where they compared Certraline to, exercise, they were equivalent, and the follow-up study, the people who continue to exercise were even better than any other group. So exercise is one of those big things that once someone gets out of depression to the point that they can start doing things for themselves, I across the board want all my patients to be exercising to some capacity. And finally, we'll talk about maybe diet. We'll talk about relationships, the importance of the importance of the of relationships. And so I'm really looking forward to the next episode. I hope that from listening

to this episode, you've gleaned some information. Hopefully, if you struggle with suicidality and you're listening to this, hopefully it can reduce a little bit of your shame to know that there's a lot of other people that struggle with suicidality. And sometimes we're genetically loaded to experience suicidality. But at the same time, there are treatments available and you're not doomed by your genes. Like the genes only influence us so much. Any final closing thoughts? I think you summed it up really nicely. I'm really excited for the next episode too.

I think getting into the treatment, the choice, what can we do to make a difference on this? This is going to be a really exciting way to end this series up. And I'm just thankful to be on the show with you. Yeah, and thank you so much. I really appreciate you and I really appreciate you helping me dig into this. You've spent countless hours doing this. We're going to put these up in the resource library,

links will be in the show notes. We'll also put up a blog for this episode. If you have any thoughts, you can send me a direct message on my Instagram, Facebook, Twitter, or through the website. And I also want to say I really appreciate all of those who have supported this podcast through Patreon. This podcast is self-funded. We're not taking any money from drug companies. We're not taking advertisers at this point. And so I really want this podcast. to remain as close as possible to the evidence without any bias. And, you know, there are some people who may not have those values. Those are some of my values.

And so, you know, we're funding this podcast by people who sign up for the CME and Patreon supporters. And hopefully that continues to grow. We're at about 20% of my goal for Patreon. So even if you want to jump on, give like $10 a month, you'll get a shirt in the mail to you, a psychiatry and psychotherapy podcast shirt, which, is the highest quality tricolor blend possible. That's a really comfortable shirt. And if $10 is too much,

I appreciate even like $5 or $1 a month. Anything like that supports. To support the podcast is really helpful. So thank you for those of you who have helped. And I really appreciate that. And we'll leave it there for today.