Psychotherapy Brown Bag

Guns and suicide - Starting a conversation as we all respond to the presidential election

by Michael D. Anestis, Ph.D.

 

Today has been a tough day for me.  I respect that, for some of you, perhaps it has been a joyous one.  I don't anticipate that either side will change the other's opinion today, but that's not my goal here.  My goal is to channel some distress and use it to be productive.  How do I plan to do that?  By starting a productive conversation about guns and suicide in America.  This short video is far from comprehensive, but it provides an overview of the issue and, hopefully, will prompt some productive thoughts and questions.

 

 

 

Recent trends in research on gun violence with respect to suicide

by Michael Anestis, Ph.D.

Over the past handful of months, I have written about a couple studies colleagues and I have published in the American Journal of Public Health on the association between state laws regulating handgun ownership and statewide suicide rates. I was very pleased to see these studies pick up some reasonably strong press coverage, with articles in the New York Times, Los Angeles Times, CNN, Charleston Gazette, and others, as well as an interview on Mississippi Public Broadcasting. Media coverage like that extends the conversation about science to a broader audience and keeps the conversation moving. Given our finding that universal background checks appear to have the most robust association with overall suicide rates, I was also extremely pleased to see President Obama’s decision to take action on extending background checks beyond their current limits. Another positive in all of that is that it has allowed me to hear follow-up questions from readers and listeners, which in turn has prompted several other recently published studies that I would like to discuss today.

Before jumping into these studies though, I'd like to take a moment to note a disturbing trend.  The US is understandably horrified by mass shootings.  They are a horrific occurrence and those who die in such conflicts and the families and friends they leave behind should be in our thoughts daily.  That being said, the large majority of gun deaths in the US are suicides and yet the conversation almost never even includes (nevermind focuses on) suicide.  If folks are serious about ending gun violence, they need to start talking about the source of most gun deaths.  If folks are serious about addressing public health concerns, they need to stop avoiding discussing of the 10th leading cause of death in the United States.

Veterans, handgun legislation, and suicide rates

The first study I’d like to discuss was just published in the Journal of Psychiatric Research. My colleague Dan Capron and I extended the handgun legislation papers to consider the associations between state veteran population rates (number of veterans per 100,000 citizens in a state), handgun legislation, and statewide suicide rates. The elevated suicide rates in active duty military personnel, National Guard and reserve personnel, and military veterans is well known and we were interested in taking a look at several factors that might at least partially explain that phenomenon.

The first point we wanted to highlight was the salience of veteran population rate in statewide suicide rates. Although not a particularly surprising finding overall, we thought the magnitude of the effect might be noteworthy and, indeed, even after controlling for important demographic characteristics (age, education levels, population density, poverty, race/ethnicity), we found that the veteran population rate predicted the overall state suicide rate, state firearm suicide rate, and proportion of suicides in a state resulting from firearms. In each case, we accounted for an enormous amount of the variance in these outcomes and the effect size was enormous. This first analysis highlights the fact that states with populations heavily saturated with veterans tend to exhibit substantially elevated suicide rates (overall and by guns alone).

The second point we wanted to address was why veteran population rate might be associated with the overall (not just gun) state suicide rate. Our assumption was that this difference would be explained by a tendency for a higher proportion of suicides having resulted from guns in states with a greater veteran population rate. To examine this, we ran a test of indirect effects, which examines the extent to which one variable (percentage of suicides resulting from firearms) explains the relationship between two other variables (state veteran population rate and state overall suicide rate). These results very clearly supported our contention in that, not only was there a direct link between veteran population rate and overall suicide rate, but there was also a significant indirect effect through the percentage of suicides resulting from firearms, again with an extremely large effect size. This second analysis highlights that the elevated suicide rates in states more heavily saturated with veterans is at least partially explained by the tendency for a greater proportion of suicides in such states to result from self-inflicted gunshot wounds.

The third and final point we wanted to address was whether veterans tend to make up a higher percentage of the population in states that do not have laws in place that have previously been shown to be associated with lower overall suicide rates (universal background checks, waiting periods, gun lock requirements, restriction of open carry – all laws specific to handguns). Here again, we found support for our hypothesis, with large effect sizes indicating that states without handgun legislation in place previously shown to predict lower suicide rates tend to have populations more heavily saturated with veterans.

So what does all of this tell us? We already know that several state laws regulating access and exposure to handguns predict lower overall suicide rates. This paper demonstrated that states with populations more heavily saturated with veterans tend to have substantially higher overall suicide rates, that this point is largely explained by the tendency of veterans to use guns in their suicide attempts, and that all of this might be facilitated by the fact that veterans tend to cluster in states with minimal handgun legislation in place.

Safe Storage of Guns and Military Suicide

The second study I want to discuss was published in Military Psychology. My co-authors were two of my doctoral students – Lauren Khazem (lead author) and Claire Houtsma – along with Kim Gratz and Matthew Tull of the University of Mississippi Medical Center. The data came from my Military Suicide Research Consortium funded grant examining suicide risk in the National Guard. Our sample was comprised of just under 1,000 soldiers, almost all of whom were soldiers in the Army National Guard (with nearly half demobilizing from deployment at the time of the baseline assessment). We were interested in the extent to which the manner in which soldiers store their personal firearms was associated with suicide risk and, as such, only included National Guard personnel who endorsed owning a private firearm (432 soldiers).

The full model we proposed was a little more complicated than that though. Following the logic of Klonsky and May’s Three Step Theory of Suicide, we noted that access to and familiarity with lethal means (e.g., guns) is an important component of the capability for suicide and a factor that can facilitate the transition from thinking about suicide to making a suicide attempt. What much of the public doesn’t necessarily know is that the vast majority of those who think about suicide do not make and attempt and the vast majority of those who make an attempt do not die. So it is incredibly important that our studies help us understand the factors that drive the transition along that continuum of risk in order to better differentiate those who will only think about suicide from those who will make an attempt. Along these lines, we had three hypotheses.

1. Soldiers who stored their guns unsafely (loaded and in an unsecure location vs unloaded and/or in a secure location) would exhibit greater fearlessness about death (another important component of the capability for suicide).
2. Storing personal firearms unsafely would increase the strength of the relationship between current thoughts of suicide and the belief that suicide was a likely outcome in the future
3. The effect from hypothesis 2 would be explained by fearlessness about death.

What we found was substantial support for the first two of those hypotheses. Soldiers who stored their guns unsafely reported significantly greater fearlessness about death. Furthermore, storing a personal firearm unsafely significantly increased the strength of the relationship between suicidal ideation and the belief that suicide was a likely outcome in the future.

Fearlessness about death did not explain the findings for hypothesis two, which means the impact of unsafe storage on the relationship between ideation and the belief that suicide is likely in the future is explained by something other than fearlessness.

So what is the take home message here? On a basic level, the findings highlight that how an individual stores their gun matters and can impact the way that they think about suicide. Now, it’s important to note that gun storage was not associated with suicidal ideation itself – so unsafe storage does not cause somebody to think about suicide. Instead, unsafe storage appears to potentially impact the extent to which thinking about suicide more broadly is associated with developing the belief that suicide is likely in the future. So in this sense, unsafe storage could facilitate the transition from ideation to action.

On a broader level, these findings highlight a potential area for common ground between gun control advocates and gun owners. Gun safety does not necessarily have to involve removing guns (at least permanently – it is highly advisable that suicidal individuals allow somebody to temporarily hold their gun for them while they experience thoughts of suicide or severe depression). Instead, it could involve the development of a culture of safety in which gun owners promote the importance of safe storage in suicide prevention. There is a model for this, as many areas mandate safe storage training in the prevention of accidents. The effectiveness of such efforts can be seen in the remarkably low level of accidental gun deaths that occur (in my state – Mississippi – fewer than 20 accidental firearm deaths occurred in 2013 as compared to approximately 200 firearm suicides).

Firearm suicides and prior suicidal behavior

The final study I want to discuss is one that I published recently in the Journal of Affective Disorders. In this one, I was interested in the extent to which suicide decedents who died from a self-inflicted gunshot wound differ from suicide decedents who died by other means in terms of prior suicidal behavior. The rationale here is that two of the most important factors used in evidence-based risk assessment procedures to determine imminent risk are the presence of suicidal ideation and a history of prior suicide attempts (in many ways a proxy for suicidal desire and the capability for suicide). We already know from prior research that certain populations (e.g., veterans, older adult males) are more prone than others to use guns in their suicide attempts and that these individuals are also prone to underreporting suicidal ideation. Because of this, these individuals are unlikely to seek out mental health care and our ability to implement evidence-based treatments for suicidality is limited because they do not identify themselves. I was curious whether those who die by suicide using a gun also report a lesser tendency to engage in previous suicide attempts (by any means). If this were the case, it would mean that, in addition to their tendency to underreport suicidal ideation, those who die using a gun are also less likely to encounter our mental health system as a result of a prior attempt (e.g., presenting in an emergency room after an intentional overdose and being referring for mental health treatment).

To address this, I used data from the National Violent Death Reporting System (NVDRS). Using data from 2005 through 2012, I was able to examine the profiles of 71,775 suicide decedents across 17 states. What I found was that, in each individual state, suicide decedents who died from a gun were less likely to have had a prior suicide attempt than were individuals who died by suicide through other methods. This was obviously then also true for the full sample, with 12.10% of firearm suicide decedents having survived a prior suicide attempt as compared to 28.66% of suicide decedents who died through other means.

This finding points to a glaring hole in our current prevention and treatment efforts. Suicidal ideation and prior suicide attempts are still remarkably important variables to consider when determining risk, but clinicians (and legislators) need to realize that our current system is in many ways ill equipped to reach the individuals most likely to die using the most common method of death in US suicides. Increasing the reach of our mental health system is a noble goal, but if the individuals most likely to die by suicide using a gun do not seek out mental health services, deny suicidal ideation when asked, and never present in health care settings as a result of a prior suicide attempt, extending the reach of that system seems highly unlikely to reach these individuals. We need to adjust our approach and, in doing so, directly address the means – guns – most likely to cause death. Whether that means legislation or simply the development of safe storage standards and open communication about the importance of managing a gun properly when suicide risk is high, steps need to actively be taken in order to address this situation.

Concluding thoughts

As folks read this, I suspect a sizable number of readers will actively wonder whether focusing on guns is missing the point. After all, many believe that if an individual who wants to die is prevented from using a gun, they will simply use another method. This idea is called method substitution and it has been repeatedly debunked through research. I could expand upon this further, but this post is getting a bit long. Let me sum it up succinctly though with a directly relevant example. If addressing guns would simply lead to folks dying by other means, the legislation papers we discussed before would not have found an association between handgun legislation and the overall suicide rate. They would have only found an association between the laws and the firearm suicide rate. As we noted though, this did not happen. The presence of laws regulating access and exposure to handguns was associated – both cross-sectionally and longitudinally – with reductions in the overall suicide rate. The is clear evidence that, when you make the most lethal method frequently used in suicide deaths harder to access, fewer people die by suicide.

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Dr. Mike Anestis is the Nina Bell Suggs Professor of Psychology and the Director of the Suicide and Emotion Dysregulation laboratory at the University of Southern Mississippi

Prolonged exposure therapy for PTSD: Separating fact from fiction

by Craig Bryan, Psy.D., ABPP

My previous blog regarding common misconceptions about the chronicity and treatment of PTSD trauma has garnered a great deal of discussion. In that blog, I specifically mentioned two psychotherapies that have garnered an especially large amount of scientific support for recovery from PTSD: prolonged exposure therapy and cognitive processing therapy. The explicit mention of prolonged exposure therapy, in particular, garnered a wide range of reactions, many of which conveyed there are widespread misunderstandings about this particular therapy. In the continued spirit of clarifying and countering common myths about trauma and PTSD, I want to take some time to clarify some of the most commonly-reported concerns about prolonged exposure therapy (which I will refer to as “PE” from this point forward).

 

CONCERN 1:

PE’s effectiveness is based on randomized controlled trials (RCTs) that only include “simple” cases. “Complex” cases characterized by multiple or repeated traumas, multiple diagnoses, and suicide risk are routinely excluded from these studies. The results of these RCTs therefore do not reflect “real life” trauma.

 

This criticism of RCTs is certainly true for some, but not the majority of, RCTs evaluating PE. It is a very common misconception that RCTs only take “simple” cases, but that’s not an accurate statement. It’s not possible for me to review every single PE study that has ever been published, but here are just a few that counter this concern:

 

1. Resick et al. (2002), Resick et al. (2012), Gradus et al. (2013): These three studies report various results from the same trial comparing PE to other treatments. Among those receiving PE, 84% of participants had a history of major depressive disorder, 52% had a history of alcohol dependence, and 18% had a history of panic disorder. Over 30% reported suicide ideation during the past week. 86% of the sample had experienced multiple traumatic events in their lives. These additional traumas included being sexually assaulted more than once (48%), physically assaulted (54%), or the target of attempted rape (36%), and 41% experienced child sexual abuse. On average, participants reported 6.4 lifetime traumas.

 

1. Foa et al. (2005): 67% of the sample had more than one diagnosis, the most common comorbidities being depression (41%), social anxiety (20%), phobias (20%), generalized anxiety (14%), and panic (12%). In addition, the majority of the sample had experienced multiple instances of trauma: 63% experienced adult rape, 76% experienced nonsexual assault, and 81% experienced childhood sexual abuse.

 

1. There are several RCTs currently underway in the DOD, VA, and civilian settings that are similarly marked by chronic, repeated trauma exposure and diagnostic comorbidities. Approximately 15-25% of the participants in these trials report recent suicide ideation.  

 

CONCLUSION: The majority of individuals enrolled in PE treatments studies are not “simplistic” cases, unless “simplistic” means being diagnosed with multiple disorders, being repeatedly abused and traumatized in life, and being suicidal.

 

CONCERN 2:

Very few trauma survivors treated with PE recover from PTSD, and when they do, the majority relapse within one year.

 

“Recovery” from PTSD can be defined in many different ways, but the most common and straightforward definitions of recovery often include (a) magnitude of clinical improvement and/or (b) loss of diagnosis. Loss of diagnosis is often considered to be the more stringent definition because it’s harder to demonstrate. Using that as our guide, we know the following:

 

1. Across 70 studies, Bisson et al. (2013) reported that the overall effect size of trauma-focused cognitive-behavioral therapy (TFCBT), which includes PE, as compared to no treatment or “usual” mental health treatment was -1.62. To put this number into perspective, an effect size value of -.20 is often considered to demonstrate “small” improvements, -.50 suggests “moderate” improvements, and -.80 suggests “large” improvements. An effect size of -1.62 across 70 studies therefore means that patients are doing enormously better as compared to those who receive no therapy at all and/or typical mental health treatment.

 

1. When comparing TFCBT such as PE to non-trauma-focused CBT, Bisson et al. (2013) reported that the overall effect size was -.27 and was -.48 when compared to non-cognitive behavioral therapy. TFCBTs such as PE are therefore slightly to moderately better than other forms of psychotherapy.

 

1. In an exhaustive review of PTSD treatments, the Institutes of Medicine (2008) reported the rates of loss of PTSD diagnosis following PE from 29 studies: 60%, 40%, 95%, 71%, 53%, 40%, 28%, 60%, 50%, 94%, 93%, 91%, 80%, 93%, 50%, 76%, 92%, 39%, 25%, 37%, 50%, 65%, 90%, 41%, 48%, 59%, 75%, 58%, and 25%. This yields an average recovery rate of 61%.

 

1. With respect to relapse, research suggests that very few patients in PE who recover from PTSD experience a relapse afterwards:

 

• Foa et al. (2005): only 8% showed reliable worsening during the next 12 months;
• Resick et al. (2012): only 5% experienced a relapse at any point during the 10 years following treatment (yes, that’s right: a 10-year follow-up study);
• Powers et al. (2010): patients receiving PE did better than 86% of patients receiving other therapies, and during follow-up 76% of patients receiving PE were still doing better than others. Although not a perfect indicator of relapse, we could use these numbers to infer that 11.6% experienced a “relapse” of some kind.

 

CONCLUSION: Although there is variability among different studies conducted with different populations, overall, the majority of patients with PTSD who receive PE will no longer have PTSD at the end of treatment. The overall size of this improvement tends to be somewhat larger than that seen in other treatments, and is very large compared to no treatment at all. Only a small proportion (5-10%) will experience a relapse or other clinical worsening during the next 1 to 10 years. Think about that for a moment: with less than 15 hours of therapy on average (the average duration of PE), the chances of recovering from PTSD are nearly 2 in 3, and if you do recover, the odds of staying recovered for at least 10 years is around 90%. There are few treatments in the mental health disciplines that have performance stats that good.

 

CONCERN 3:

Patients receiving PE are much more likely to drop out of treatment than patients receiving other treatments.

 

This is a common concern about PE, but let’s look at what the science tells us about dropout in PE as well as psychotherapy in general.

 

1. When looking at individual PE trials, the typical dropout rate is usually between 25-35%. For example:

 

• Resick et al. (2002): 27% dropout rate;
• Foa et al. (2005): 32% dropout rate;
• Tuerk et al. (2011): 34% dropout rate.

 

1. When looking across 70 published studies, Bisson et al. (2013) reported that the dropout rate among trauma-focused cognitive behavioral therapies (which includes PE) was 19% on average as compared to 13-15% on average in non-trauma therapies.

 

1. In a different analysis of 669 studies, Swift & Greenberg (2012) reported that the mean dropout rate in psychotherapy as a whole is around 20%. Regardless of the type of treatment received, patients with PTSD had the relative highest rates of dropout (25%). This means that patients with PTSD are among those most likely to drop out of therapy of any kind, even therapies other than PE.

 

CONCLUSION: Out of 100 patients, 20-33 drop out of PE early as compared to 13-25 who drop out of other therapies early. Overall, this suggests that there is some truth to the statement that PE has higher dropout rates, but this rate is not much higher than dropout rates among trauma survivors in general, regardless of the treatment received.

 

CONCERN 4:

Conclusions about PE are based only on treatment completers, which inflates the apparent effectiveness of the treatment.

 

This concern is based on a well-known truth about most medical treatments and psychotherapies: those who finish the treatment as prescribed generally do better than those who drop out of therapy early. As we discussed above, in real life approximately 1 in 5 patients who will drop out of treatment early. High quality clinical trials therefore often analyze the results in two ways: treatment completer and intent to treat analyses.

 

• A treatment completer analysis ignores dropouts and pays attention only to those who finish a treatment. This provides us with an understanding of how effective the treatment is if someone gets the full dose.

 

• An intent to treat analysis includes all participants who start the treatment, even if they don’t finish it. In other words, both the treatment completers and the dropouts are included. This type of analysis provides us with an understanding of how effective the treatment is with respect to the overall population of individuals accessing care. This is a more conservative estimate, but it is more generalizable to “real life.”

 

Intent to treat analyses are considered “best practice” for clinical trials, as it enables us to estimate the number of patients who will improve in “real life” if they were to simply walk in the door and start receiving a particular treatment. As applied to PE, Resick et al.’s (2002) intent to treat analysis suggested a 53% recovery rate from PTSD following PE, but the treatment completer analysis suggested an 83% recovery rate. By comparison, the recovery rate was only 2% for those who did not receive treatment. Similar findings were reported by Foa et al. (2005) and Tuerk et al. (2011), suggesting those who complete PE fare approximately 50% better than the overall group of patients who start (but don’t necessarily finish) PE. 

 

CONCLUSION: For every 100 patients who seek out treatment for PTSD, 50 will recover if they start PE (even if they don’t complete the treatment), but over 80 will recover if they finish the treatment. By comparison, only 2 will recover if they receive no treatment at all. This suggests that someone who starts PE, even if they don’t finish the treatment, is approximately 25 times more likely to recover from PTSD than someone who receives no treatment at all! Thus, although treatment completer analyses do yield higher recovery rates, it’s notable that receiving any amount of PE will likely be highly beneficial to trauma survivors.

 

CONCERN #5:

PE shouldn’t be offered to anyone because the treatment didn’t work for me/my family member/my friend.

 

This is the most difficult concern to respond to, because it highlights the limits of our knowledge: we do not yet have any treatment that is 100% effective for PTSD. Unfortunately, although PE often leads to positive outcomes, it does not work for all trauma survivors all the time. We’re starting to understand, for instance, that there are different types of trauma that may influence how a person responds to treatments like PE.

 

This limitation to our knowledge doesn’t mean that PE (or any other scientifically-supported trauma therapy) should be abandoned or dismissed, however. Consider this logic as applied to something like cancer. Chemotherapy is a useful and scientifically-supported treatment for cancer, but sometimes individuals with cancer nonetheless die of cancer despite receiving chemo. Because chemo is such an uncomfortable treatment with many very unpleasant side effects, we might conclude that it’s reasonable to withhold this “harmful” treatment from other cancer patients because it doesn’t work as well as we’d like for everyone. This would be very irresponsible, as it would effectively restrict a potentially life-saving treatment from a large number of cancer patients. We must be cautious not to make the same mistake for trauma survivors.

 

CONCLUDING THOUGHTS

 

Because the dissemination of false information about treatments like prolonged exposure therapy could potentially get in the way of trauma survivors taking their lives back, we must commit ourselves to understanding the facts about PTSD and its treatment. Too many people are tormented by the shadow of past traumas, and they deserve nothing less than accurate information about those treatments that can serve as a light in their darkness. Although PE may not work for all trauma survivors all the time, it has consistently proven to be a very good option for many individuals with PTSD.

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Dr. Craig J. Bryan, PsyD, ABPP, is a board-certified clinical psychologist and the Executive Director of the National Center for Veterans Studies at The University of Utah. He is a veteran of the Iraq War, and is a nationally-recognized researcher and clinician in the areas of trauma and suicide.

No, PTSD is NOT a chronic condition (at least it doesn't have to be)

by Craig Bryan, PsyD, ABPP

The recent NYTimes piece about a unit of Marines who have struggled with combat-related PTSD and suicide has reignited public conversation about military and veterans mental health, suicide prevention, and mental health treatment. During the course of these discussions, many myths and misconceptions about PTSD and its treatment have arisen. Because some of these misconceptions could potentially serve as barriers to good, effective treatment, I wanted to take some time to desconstruct and address two myths about treating PTSD among military personnel and veterans.

Myth #1: Suicide among military personnel and veterans is the result of combat trauma

First, I want to make sure to remind us all that less than half of veterans who die by suicide deployed in any capacity, and even fewer experienced combat directly. I realize that the NYTimes piece focused on a combat unit and their struggles with suicide, but if there’s one thing I’ve learned over the past decade, it’s that when we hear poignant and tragic stories such as this one, we easily forget that trauma and suicide impact even those service members and veterans who have not deployed.

Myth #2: PTSD is a chronic condition that cannot be effectively treated

Second, I would like to address what appears to be some misconceptions about trauma and PTSD. Specifically, I want to address the implication that (a) PTSD is a chronic, untreatable condition, and (b) that treatment for PTSD must be long-term by default. We now have approximately 30-40 years of research clearly demonstrating that PTSD can be effectively treated to remission, but these effects seem to be limited to only a handful of therapies. Unfortunately, most mental health clinicians don’t know how to do these therapies, and (even more stunning) very few even know that they exist.

There is now overwhelming consensus by trauma experts that certain forms of trauma-focused therapy (e.g., prolonged exposure therapy, cognitive processing therapy) are incredibly effective and lead to remission from PTSD in 2 out of 3 cases on average, and in some cases in as many as 9 out of 10 of cases (Institute of Medicine, 2008). These treatments typically last for only 10-12 outpatient sessions on average. If you were to deliver these therapies in the typical one-hour-per-week format, this means recovery can occur in less than 3 months on average. We now have anecdotal evidence, published case reports, as well as controlled scientific studies that these therapies can be administered every day instead of once per week (like usual) and you can get the same benefits (Ehlers et al., 2014). Indeed, in my own clinical work, I periodically accept military veterans for two weeks of intensive cognitive processing therapy in which we meet every morning for therapy instead of just once per week. This intensive approach leads to the loss of PTSD just as often as it does when I meet with a patient at a slower, more traditional pace of once per week. This is incredibly hopeful news for trauma survivors: it is feasible to be effectively treated for PTSD very quickly, and the effects last for up to 10 years (Resick et al., 2012). This is a very different picture from what we have historically believed about PTSD.

The good news is that we’ve learned a LOT about treating PTSD during the past 40 years, and we’re now very good at doing so. Even more encouraging is the emergence of new data from recent and ongoing PTSD treatment studies that these really good therapies also reduce suicidal ideation (Gradus et al., 2013), contrary to a very common and pervasive myth that trauma survivors cannot be safely treated with trauma-focused therapies because they are “too fragile” or “can’t handle it.” I personally find this perspective amongst clinicians to be especially heartbreaking, as it communicates to the patient that he or she truly is broken, that they really can’t handle things, and that they are indeed incapable of living lives worth living. Is it any wonder that so many trauma survivors don’t get better when this is the message they are receiving, even if only implicitly, from the very individuals who are supposed to be trained to help them recover?

So… why do so many people (mental health clinicians included) believe that PTSD is chronic? Because the vast majority of clinicians were never trained to use state-of-the-art therapies, and the vast majority of trauma survivors have never received these therapies. The “status quo” right now is to use antiquated or untested techniques based on outdated and/or pseudoscientific ideas. We are, in essence, stacking the deck in such a way that we can only confirm the very (mis)conceptions about PTSD we hope to disconfirm.

I can’t stress this enough: it is no longer true that PTSD *has* to be chronic. It is also untrue that a trauma survivor will never be able to see and experience a reality that is not colored by their tragedy and suffering.  With the right kind of therapy delivered by the right kind of clinician, recovery from PTSD can occur in a stunningly rapid period of time for the majority trauma survivors, to include military personnel and veterans. Trauma survivors no longer have to live in darkness and despair, and they don’t have to spend years of their lives and untold fortunes for “therapy” that doesn’t work. Some treatments work better than others. We need to ensure that these better treatments become the first (not the second or the third or the tenth) treatments that trauma survivors receive.

Final Thoughts

It is easy to wave the banner of “providing the best care possible for our veterans,” but I have yet to see a concerted public effort to demand that mental health professionals receive training in anything other than scientifically supported treatments. It is also easy to beat the drum for “improved access to care” and “treatment works,” but calls for improved access to care without any discussion about the quality of that free/low cost/convenient care is not helpful. Easy access to bad therapy (even if it’s free) is not good enough.

To me, the most troubling question implicated by the NYTimes piece was not “Why doesn’t the VA do more?” but rather “Why was the VA the *only* viable option available to these men?” It’s easy to point our collective fingers of blame at the system, but we should also keep in mind that what this story implies is that these men did not have access to *any* appropriately-trained mental health professional in their communities, to include non-VA options. This is a tragedy that we must fix, not only for our veterans, but for all of our family members and friends.

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Dr. Craig J. Bryan, PsyD, ABPP, is a board-certified clinical psychologist and the Executive Director of the National Center for Veterans Studies at The University of Utah. He is a veteran of the Iraq War, and is a nationally-recognized researcher and clinician in the areas of trauma and suicide.

Limiting access to lethal means helps prevent suicide....but not because suicide is impulsive!

by Michael D. Anestis, Ph.D.

Over the past month or so, I feel as though I've seen a surge of articles recognizing suicide as the primary factor in gun related deaths in the US and promoting the utility of means restriction and means safety in preventing suicide.  Our lab has been fortunate to be involved in some of those articles (New York Times, Los Angeles Times, CNN, Mississippi Public Broadcasting, Charleston Gazette), but the media coverage has extended well beyond our work.  Ultimately, this coverage has rightfully touted the powerful role that firearms legislation (means restriction) and gun safety efforts (means safety) can have in preventing suicide.

This is, without question, a positive development and I want to make sure that the conversation remains almost entirely focused on that fact.  When suicide is in the national conversation, that's good news for suicide prevention.  When means restriction/safety is discussed as a potential tool for preventing suicide, that's remarkably good news for those suffering with thoughts of suicide.  Nitpicking about errors at the expense of good coverage is a disservice to the field.

I'm still a nerd though and I can't help but feel a bit frustrated by a common thread throughout much of this news coverage: the idea that means safety works because "suicide is impulsive," so restricting access in the moment works because it prevents an unplanned and explosively emerging behavior from occurring.  On an intuitive level, I can kind of see the logic there, but the data simply do not back up this assertion and this has serious clinical implications.

As I've noted several times on PBB before, we've done a lot of work on the relationship between impulsivity and suicide (here's an article I wrote summarizing some of that work a while back). What we found in a review paper published in Personality and Social Psychology Review was that:

(1) How impulsive an individual is in general has only a small relationship with prior attempts, is a poor predictor of future attempts, and is unrelated to death by suicide

(2) The small relationship between how impulsive an individual is and suicidal behavior is mediated (statistically explained) by the painful and provocative behaviors that impulsive individuals tend to encounter at a higher rate and which, over time, facilitate an individual's ability to engage in suicidal behavior
(3) Studies that have attempted to measure how impulsive specific suicide attempts have been crippled by enormous methodological problems and, for obvious reasons, are limited to non-lethal suicide attempts (which appear likely to differ from lethal suicidal behavior in a number of meaningful ways).

One of the issues to consider here is what we mean when we say a suicide attempt is impulsive.  If an individual has been thinking off and on about a suicide attempt for an extended period of time, but was not thinking about it continuously in the days and weeks leading up to an attempt, how we ask the question might prompt that individual to say he or she started thinking about suicide in the moments leading up to the behavior.  In some ways, you could argue then that the behavior emerged suddenly.  At the same time....doesn't that describe almost all of our behaviors during a given day?  How many behaviors did you plan extensively for days or even hours at a time leading up to the decision today?  It seems we may be holding suicide to a different standard here, which has important clinical implications because, if suicide emerges suddenly without warning or plans, our ability to prevent it would be very stunted. 

Stephanie Pennings, Tabatha Williams, and I addressed this question with a recent study in which we showed that the most common response for individuals with a suicide attempt is that they had been thinking off and on about attempting suicide using the actual method they ultimately chose (so not just thinking about it in general) for a period of years leading up to the attempt.

So....the weight of the evidence seems to support the idea that suicide is rarely if ever an impulsive and unplanned behavior.  People need to stop thinking about suicide as a frantic and sudden escape from acute crises and instead think about it as a calculated pursuit of death that requires a willingness to persist through the pain, discomfort, and fear that comes along with suicidal behavior (here's David Klonsky talking about this very topic in an exceptional recent article in the Psychiatric Times)

So why is this particularly relevant to firearms suicide?  Well, if we cast aside concerns regarding how the impulsiveness of a specific suicide attempt is measured, you'll note that there is a consistent finding that the more impulsive a suicide attempt is, the less lethal that attempt tends to be.  If that's the case, it would indicate that impulsive attempts (if they happen) do not involve firearms, which have a lethality rate greater than 80%.

****

Okay then....if means restriction/means safety does not work because of impulsivity, why does it work?  This question requires more research, but here's my response:  suicide is hard.  If you accept the "non-impulsive" model, then you can embrace the idea that individuals spend a good amount of time thinking about and preparing themselves to use a specific method that suits them to engage in a behavior that is terrifying.  When you make that terrifying behavior that much more difficult, you lower the odds that it will ultimately happen.  That might sound simple, but to me it seems to align with most other things in life.  There are plenty of behaviors we are ambivalent about or resistant to on any given day and, when something makes them a bit harder, we often opt against doing them.   

Like I said earlier, my overall feeling is that it is wonderful that the media is discussing firearms and suicide.  Despite accounting for a large majority of firearm deaths in the US, suicide has historically been left out of the conversation, so this is a big step.  That being said, let's not get ahead of ourselves by promoting faulty models of suicide that do not align with the data.  Doing so weakens our arguments, promotes the continued survival of myths about suicide, and leaves experts arguing with each other (something I'm clearly contributing to here) rather than working together to promote suicide prevention.

**********

Mike Anestis, Ph.D. is the Nina Bell Suggs Professor of Psychology at the University of Southern Mississippi and the director of the Suicide and Emotion Dysregulation lab.

State laws regulating access to handguns are associated with lower overall suicide rates

by Michael D. Anestis, Ph.D.

A few months ago, I posted here about a study that several students and I had published in the American Journal of Public Health looking at the relationship between a series of state laws regulating handgun ownership and overall suicide rates.  The study demonstrated a robust effect of regulations on suicide rates, further highlighting the importance of managing access to highly lethal means when considering suicide prevention.  In that paper, my colleagues and I selected laws based upon their coverage by the NRA-ILA, with the idea being that we wanted to ensure that nobody could accuse us of cherry picking laws to manipulate the results (after all, the NRA picked the laws).  That being said, I don't think the laws we studied in that paper were the ones likely to exhibit the strongest effect.  Instead - based on David Klonsky and Alexis May's Three-Step Theory of Suicide, which posits that access to and familiarity with lethal means is an important component of the capability for suicide - I thought background checks, waiting periods, gun lock requirements, and restriction of open carry would be better candidates.  These laws, after all, should diminish access and exposure to handguns.

All this being said, with the initial study published, Joye and I decided to examine these other laws and the results were unambiguous in their support of the potential role of legislation of handguns with respect to overall suicide rates.  This paper was also just published in the American Journal of Public Health.  If you want a quick summary of the results, click on the Youtube video below, in which I explain the results in just over a minute.  Below the video, I will explain them in more detail and reflect upon their implications.

For our first set of analyses, we tested each of the four laws (background checks, waiting periods, gun lock requirements, restriction of open carry), examining whether the presence of the law was associated with a lower overall suicide rate, firearm suicide rate, and percentage of suicides resulting from firearms in 2013 (the most recent year with official data available), even after accounting for age, education, poverty, race/ethnicity, and population density.

This table shows you the different rates in states with versus without each of the laws:

Variable	No.	Statewide Suicide Rate for 2013, Mean (SD)	Statewide Suicide by Firearm Rate for 2013, Mean (SD)	Statewide Deaths by Firearms for 2010, %, Mean (SD)
Waiting period
Yes	11	11.45 (2.82)	4.43 (2.57)	35.8 (17.1)
No	40	15.72 (3.72)	8.98 (3.07)	55.8 (11.6)
Background check
Yes	17	11.42 (3.06)	4.53 (2.62)	36.8 (16.2)
No	34	16.49 (3.18)	9.74 (2.43)	58.8 (7.6)
Open carry restricted
Yes	20	12.16 (3.44)	5.58 (3.38)	42.1 (18.9)
No	31	16.50 (3.27)	9.56 (2.60)	57.5 (8.0)
Gun lock required
Yes	4	9.20 (0.91)	2.68 (1.02)	28.5 (8.0)
No	47	15.28 (3.72)	8.45(3.25)	53.4 (14.1)

A quick look makes it clear that the rates were quite different in those with versus without various forms of legislation.

We next looked at whether these laws had a significant effect on each of those outcomes even after controlling for the list of demographic variables I listed earlier.

Variable	Statewide Suicide Rate for 2013			Statewide Suicide by Firearm Rate for 2013			Statewide Proportion of Suicide Deaths by Firearms for 2013
	R2	b(95% CI)	ph2	R2	b (95% CI)	ph2	R2	b (95% CI)	ph2
Set - Waiting Period	0.43			0.60			0.74
Population density		0.000 (–0.001, 0.001)	0.00		0.000 (0.000, 0.001)	0.01		0.000 (0.000, 0.000)	0.02
% of state below poverty     line		–0.211 (–0.633, 0.211)	0.02		–0.112 (–0.425, 0.201)	0.01		0.005 (–0.006, 0.016)	0.02
% aged|>|25 y with     college degree		–0.293* (–0.582, 0.003)	0.09		–0.360** (–0.574, 0.145)	0.21		–0.014** (–0.021, 0.006)	0.23
% White		0.057 (–0.012, 0.126)	0.06		0.054* (0.003, 0.105)	0.09		0.002* (0.000, 0.004)	0.11
Median age		–0.318 (–0.727, 0.091)	0.05		–0.298 (–0.602, 0.005)	0.08		–0.011* (–0.022, 0.000)	0.09
Waiting period		2.271 (–0.339, 4.881)	0.07		2.366* (0.430, 4.303)	0.12		0.072* (0.003, 0.140)	0.09
Set - Background Check	0.51			0.67			0.77
Population density		0.000 (–0.001, 0.001)	0.00		0.000 (–0.001, 0.001)	0.00		0.000 (0.000, 0.000)	0.06
% of state below poverty     line		–0.187 (–0.565, 0.191)	0.02		–0.074 (–0.351, 0.203)	0.01		0.006 (–0.004, 0.016)	0.03
% aged|>|25 y with     college degree		–0.169 (–0.445, 0.108)	0.03		–0.245* (–0.448, 0.043)	0.12		–0.010** (–0.017, 0.003)	0.15
% White		0.046 (–0.018, 0.109)	0.05		0.047* (0.001, 0.094)	0.09		0.002* (0.000, 0.003)	0.10
Median age		–0.254 (–0.637, 0.129)	0.04		–0.253 (–0.533, 0.028)	0.07		–0.009 (–0.019, 0.001)	0.07
Background check		3.519** (1.294, 5.744)	0.19		3.146***(1.517, 4.775)	0.26		0.099** (0.040, 0.157)	0.21
Set - Open Carry	0.50			0.64			0.75
Population density		0.000 (–0.001, 0.001)	0.00		0.000 (–0.001, 0.001)	0.00		0.000 (0.000, 0.000)	0.05
% of state below poverty     line		–0.136 (–0.511, 0.239)	0.01		–0.024 (–0.309, 0.261)	0.00		0.008 (–0.003, 0.018)	0.05
% aged|>|25 y with     college degree		–0.215 (–0.486, 0.057)	0.05		–0.292** (–0.499, 0.086)	0.16		–0.012** (–0.019, 0.004)	0.18
% White		0.051 (–0.011, 0.114)	0.06		0.055* (0.008, 0.103)	0.11		0.002* (0.000, 0.004)	0.12
Median age		–0.414* (–0.787, 0.040)	0.10		–0.394** (–0.677, 0.110)	0.15		–0.014* (–0.024, 0.003)	0.14
Open carry restricted		3.025** (1.092, 4.957)	0.18		2.381** (0.912, 3.850)	0.20		0.066 * (0.013, 0.120)	0.13
Set - Gun Locks	0.46			0.60			0.76
Population density		–0.001 (–0.002, 0.001)	0.03		0.000 (–0.001, 0.001)	0.01		0.000 (0.000, 0.000)	0.12
% of state below poverty     line		–0.024 (–0.421, 0.374)	0.00		0.062 (–0.243, 0.367)	0.00		0.011* (0.001, 0.021)	0.10
% aged|>|25 y with     college degree		–0.144 (–0.448, 0.160)	0.02		–0.241* (–0.474, 0.008)	0.09		–0.009* (–0.016, 0.001)	0.10
% White		0.072* (0.009, 0.135)	0.11		0.072** (0.024, 0.120)	0.17		0.002** (0.001, 0.004)	0.18
Median age		–0.356 (–0.748, 0.037)	0.07		–0.349* (–0.650, 0.048)	0.11		–0.012* (–0.022, 0.002)	0.12
Gun lock required		4.085* (0.456, 7.713)	0.11		3.073* (0.291, 5.855)	0.10		0.137** (0.043, 0.230)	0.17

There are several important things to note in this table.  First of all, almost every single effect was statistically significant (which is remarkable on its own, given that there was a sample size of only 50 states and DC) and the one non-significant one had a medium effect size.  Second, many of the effect sizes were enormous and each analysis accounted for a remarkably high percentage of the variability in our outcomes.  Put another way, the relationship between law and suicide rates was huge and this isn't a situation where we talk about statistical significance with little real world value.  Instead, we accounted for the majority of the variability in most of our outcomes.  That's simply not something you find often in social sciences, particularly when you talk about low base rate events like suicide.

For our next set of analyses, we wanted to test whether each law had an indirect effect on overall suicide rates through the percentage of suicides resulting from firearms.  What this means is that we wanted to see if the way these laws impact overall suicide rates (not just firearm suicide rates) is through their impact on the percentage of suicide deaths resulting from firearms.  Results consistent with that idea would indicate that the laws work through one or more of the following ways: reducing the overall number of attempts, leading people to attempt with less lethal means, or reducing the number of handguns owned within the state.  The table below shows you the results.

Independent Variable	R2	Coefficient (SE; P) or Bootstrap Coefficient (SE; 95% CI)	Ratio Indirect:Total	k2
Waiting period	0.42		0.67	0.29
Total		-4.28 (1.21; .001)
Direct path		-1.42 (1.25; .261)
Indirect path		-2.86 (0.93; -5.30, -1.42)
Background check	0.46		0.45	0.26
Total		-5.07 (0.93; <.001)
Direct path		-2.77 (1.21; .026)
Indirect path		-2.30 (0.89; -4.28, –0.73)
Open carry	0.29		0.44	0.25
Total		-4.35 (0.96; <.001)
Direct path		-2.42 (0.97; .016)
Indirect path		-1.93 (0.69; -4.36, –0.47)
Gun lock	0.18		0.59	0.25
Total		-6.07 (1.88; .002)
Direct path		-2.47 (1.77; .169)
Indirect path		–0.3.60 (1.01; -6.06, -1.93)

As you can see, in each case, the laws had a significant indirect effect through the percentage of suicides resulting from firearms and, here again, the effect sizes were impressively large.

So before moving on, let's recap what we've learned so far. 

(1) States with one of these laws in place  had lower overall suicide rates, firearm suicide rates, and percentage of suicides resulting from firearms. 

(2) The laws appear to impact overall rates largely through their ability to reduce the percentage of suicides resulting in firearms.

A reasonable critique of those findings would be that we looked only at a single year.  Given that, it could be that the states that had these laws in place would have had lower suicide rates anyway and that the laws themselves aren't the causal force.  To address this, we acquired a list of states that changed any of these laws from 2009-2013 from the Law Center to Prevent Gun Violence.  We found four such changes.  During this period, California restricted open carry, DC extended their waiting period, Oklahoma restricted open carry, and South Dakota repealed their waiting period.  So what happened with these changes?

• In the year after restricting open carry, California saw a 3.5% decrease in its suicide rate whereas the nation as a whole (excluding California) saw a 2.1% increase.  From the year of enactment through 2013, California saw a 1.0% decrease in their suicide rate whereas the nation as a whole saw a 2.7% increase.

• In the year after extending their waiting period, DC saw a 2.2% decrease in its suicide rate whereas the nation saw a 2.1% increase.  From the year of enactment through 2013, DC saw a 1.5% decrease whereas the nation saw a 2.7% increase.

• In the year after restricting open carry, Oklahoma saw a 1.7% decrease in its suicide rate whereas the nation saw a 0.6% increase.  This law was changed in 2012, so the data are the same for the year of enactment through 2013.

• In the year after repealing their waiting list, South Dakota saw a 7.6% increase in its suicide rate whereas the nation saw a 3.3% increase.  From the year of enactment through 2013, South Dakota saw an 8.9% increase whereas the nation saw an 8.2% increase.

So...enact a law and your rate goes down in subsequent years even as the national rate goes up.  Repeal a law and your rate increases more steeply than that of the nation as a whole.

Before wrapping up, we ran one last series of analyses.  To provide some context, we examined the relationship between three non-controversial traffic laws (no texting while driving, hands free cell phone use, and primary enforcement of seatbelt use) on traffic deaths, controlling for the same demographic factors.  In each case, the traffic law was not significantly related to traffic deaths.  Does this mean texting while driving, using a hand held cell, or not using your seatbelt aren't dangerous?  Of course not.  What it means is that legislating those behaviors doesn't seem to impact death.  Indeed, it is a cultural norm to be safe when it comes to such behaviors, so individuals do this on their own and the legislation might not be necessary for the behaviors to take root and have their impact on traffic injuries and deaths.  That same cultural norm is not present for gun safety and, as such, the laws have a strong effect, as they increase the odds of gun safety.  Nobody is proposing the legislation solves everything or is equally effective for all behaviors.  Rather, it seems like legislation might prove useful when cultural norms value unsafe behavior over safe behavior and individuals are not intrinsically motivated to act safely.

So what does this all mean?  Our results point towards legislation as one potentially powerful tool in substantially reducing the suicide rate.  That effect is likely explained largely through a decrease in gun ownership and is consistent with the mountains of evidence showing that when you restrict access to lethal means, the suicide rate goes down and those reductions are sustained.  Given evidence contradicting the common belief that "those who really want to die will simply find another way if you take the gun away," this represents a potential solution to a serious public health concern.

That being said, large portions of this country strongly oppose gun regulation and, in some parts of the country, that outcome simply isn't realistic.  Because of this, as a resident of Mississippi I propose the following:

The quickest and most powerful way for us to reduce the suicide rate in the US might be for suicide prevention experts to partner with state governments and gun safety educators to develop publicity and education campaigns emphasizing gun safety among gun owners.  When we talk about guns, we have to start talking about suicide (which accounts for well over half of all gun deaths in the US) and when we talk about guns and suicide, we might need to think less about regulation and more about the common ground we can find through education.  I don't like guns, but that's irrelevant here.  What matters is that we all dislike suicide and want to prevent it.  Here's our common path.  Don't single out the mentally ill - folks showing up in emergency rooms and psychology clinics are not representative of most the individuals who die by suicide using a gun - but instead focus at the population level and provide legitimate education on suicide risk factors and means safety options for all gun owners when they acquire a gun.  Promote statewide conversations about suicide.  Shift the cultural norm such that people see having somebody keep their gun for them when they're upset as akin to having somebody keep their keys when they've consumed alcohol.  Means safety will not eliminate suicide, but it will reduce the overall capacity for suicide in our nation, thereby increasing the strength of our various effective therapies that aim to address suicidal thinking.  There aren't often clear paths to robust impacts on severe public health concerns, but this seems to be one.  The question is whether we use this information to inspire productive action or if we waver, pause, and revisit this years later, having failed to save the thousands of lives that might otherwise have been saved.

**********

If you'd like to see some media coverage of this study, you can see some in the New York Times and Mississippi Public Broadcasting.  You can also read an editorial I recently published on this topic in the Hattiesburg American.

Mike Anestis, Ph.D. is the Nina Bell Suggs Professor of Psychology and the director of the Suicide and Emotion Dysregulation lab at the University of Southern Mississippi.

Virtual Clinical Lunch Series by SSCP: Steve Hollon on whether the effects of CBT are enduring or short lasting

by Michael Anestis, Ph.D.

 

The Society for a Science of Clinical Psychology (SSCP) is one of my academic homes and a driving voice behind the use of science to guide our conceptualization and treatment of mental illness.  This year, SSCP is beginning a new initiative that Joye and I think represents a truly valuable contribution to the field and those in need of help: a Virtual Clinical Lunch.

Each month, SSCP will post a talk online featuring a prominent scientist discussing one or more topics related to the SSCP mission.  The idea is to disseminate the material widely and then for graduate programs, clinicians, and those in need of help for mental illnesses to listen and share their thoughts across various forums.  Additionally, the scientist featured in the monthly talk will take and respond to questions on the SSCP listserv in the weeks following the posting.

This month, SSCP has launched its initial talk, featuring SSCP President-Elect Steve Hollon, Ph.D. discussing whether the effects of CBT are enduring or transient.  I'm certainly looking forward to listening and hope that you will not only do so as well, but that you will also send the link around broadly (social media, email, etc...) so that we can maximize the number of people who benefit from the material.

 

Always great to see some of the field's brightest minds reaching out to a wide audience with a message of clinical science!

The "Ideation to Action" framework: Shifting how we think about suicide risk

by Michael D. Anestis, Ph.D.

Last night, I was having a conversation on Twitter during which an individual mentioned that a focus on means restriction - making it more difficult for individuals to gain access to highly lethal methods for suicide - is problematic because it doesn't focus on the "causes."  He mentioned depression and hopelessness as causes, which makes sense in a lot of ways, but I would argue that this response is not only off base, but is also emblematic of a larger problem in how we think about suicide risk.

Over the past year or so, I've really shifted most of my work to explicitly consider what is referred to as the "ideation to action" framework.  The phrase comes from David Klonsky and Alexis May (click here for a link to one of their great papers) and refers to the need for folks thinking about suicide risk to get away from building a never ending list of risk factors for suicide overall and instead to work on understanding what prompts suicidal ideation versus plans versus non-lethal attempts versus death and in what contexts those variable have the most influence.  Another way of thinking about this is that they called for researchers to focus on moderators and mediators rather than simple main effects and to be more specific about the precise nature of their outcome variables.

To clarify why this is so important, think about it this way....

At any given moment, most people are not thinking about suicide

Unfortunately, however, a sizable minority are having such thoughts

Nonetheless, the vast majority of those individuals thinking about suicide will not make an attempt.

Taking it a step further, the vast majority of those who do attempt, will not die from that attempt.

As it turns out, we're not particularly good at determining ahead of time which individuals will end up in that final group - the folks who unfortunately die by suicide.  In fact, recent work by Joe Franklin and others from Matt Nock's lab demonstrated that we're no better at predicting this now than we were in the middle of the last century.  Think about that for a second....it's not good.

A major reason for this is that so much of our attention has been set on building a list of variables associated with "risk" overall rather than understanding the more nuanced relationships that lead to somebody moving from the largest group (no thoughts of suicide) to the smallest one (suicide decedent).

The things that prompt an individual to think about suicide are not necessarily the things that facilitate that individual transitioning from thoughts to attempt or death.  Remember, most people never make that transition.  Given two people - one who is depressed and one who is not - I would assume greater risk for eventual death by suicide in the depressed individual, but given two depressed individuals, I have no way of determining who is at greater risk and, by far, the most likely outcome is that neither will attempt or die.  We need better information to understand that transition from ideation to action.

One way of thinking about this is using Joiner's Interpersonal Theory of Suicide (ITS).  Joiner notes that serious or lethal suicidal behavior is only likely when both suicidal desire (driven by a sense of isolation, a belief that one's death is worth more to others than their continued life, and hopelessness that this will change) and the capability for suicide are present.  Suicidal desire makes intuitive sense, but the capability part is a bit different.  In Joiner's theory - and substantial research has now backed this up - the capability is comprised of an elevated tolerance of physical pain and a diminished fear of death and bodily harm.  Suicide is scary - even when it is desired - and we are genetically programmed to try and survive.  Persisting through catastrophic damage to our body in pursuit of death is something that most people simply (and thankfully) cannot do, which is one of the primary reasons why most individuals who think about suicide never attempt and most who attempt do not die.  It's hard to do.  Individuals need to either innately have the capability to do this or they need to develop it over time through repeated exposures to and experiences with events that change our relationship with death and pain (e.g., non-suicidal self-injury, prior suicide attempts, physical abuse, witnessing death).

So by thinking about whether, how, and in what contexts a variable contributes to the desire versus the capability for suicide, we position ourselves to better understand those who need help but are unlikely to die from those who need help and are at greater risk to themselves.

An example of this that we have looked at quite a bit in our lab recently is emotion dysregulation (click here for a link to a review paper summarizing this research).  We have repeatedly found that individuals who are overwhelmed by, have difficulty identifying and tolerating, and feel the need to immediately escape negative emotions are more likely to think about suicide.  That's not earth shattering news, but the more complicated part of that is that, in non-suicidal individuals, those same difficulties predict less capability for suicide and in individuals with prior suicide attempts, those difficulties are no longer associated with actual suicidal behavior once we consider the impact of other behaviors (e.g., non-suicidal self-injury) that emotionally dysregulated folks tend to engage in.  That might sound a bit weird - after all, emotionally dysregulated individuals die by suicide at an elevated rate and a treatment with great success in reducing suicide risk (dialectical behavior therapy) focuses largely on increasing distress tolerance and building emotion regulation skills - but when you consider the ideation to action framework is makes quite a bit of sense.  Being chronically overwhelmed by your emotions certainly prompt an individual to think about suicide or any other option that might seem to offer a way not to feel these distressing states.  But remember, suicidal behavior is difficult, frightening, and often very painful.  That type of behavior does not offer immediate relief....it requires someone to prioritize dying over immediate escape from discomfort.  When you think about it that way, emotion dysregulation on its own might make someone less capable of suicidal behavior.  Instead, they might choose another behavior that offers immediate relief without the same fear or required persistence like non-suicidal self-injury.  But what if that individual engages in that behavior many times over an extended period?  That might change their relationship with pain and death and, eventually, make that individual capable of acting. 

In the above scenario, emotion dysregulation facilitated suicidal desire, but it was chronic non-suicidal self-injury that facilitated the capability for suicide and prompted the transition from ideation to action.

Why is that important to consider?  When we're making decisions about imminent risk with a client and trying to determine the best available intervention, we are best able to do so when we have a clearer sense of where they are on the ideation to action continuum.  We'll likely never be perfect, but by asking the right questions, we can up our odds of providing optimal care.

I could go on about this for a LOOOOONG time, but I don't think anyone wants to read that much, so let me wrap this up by returning to what prompted this post.  The individual who wanted to de-emphasize means restriction to focus on depression, in my opinion, was missing the point because his focus is on a variable that - while important - really only strongly predicts an individual landing in the larger suicidal ideation group rather than a variable that might facilitate shifting from ideation to action.  Klonsky in his new Three-Step Theory of suicide risk argues that access to and familiarity with lethal means (e.g., guns) is actually a component of suicidal capability.  Given our recent work on the impact of state laws regulating handgun ownership and statewide suicide rates, I think he makes a strong point there.  If we go along with that idea, then by restricting access to those means, we are diminishing capability for suicide and, remember, in the absence of capability, suicidal desire is highly unlikely to transition into action.  Now, don't get me wrong, I'm not saying we should not treat the depression.  Of course we should, but as one component of risk prevention.  An individual receiving behavioral activation for depression is still an individual who could benefit greatly from diminished capability for suicide.

*****

Mike Anestis, Ph.D., is the Nina Bell Suggs Professor of Psychology at the University of Southern Mississippi and the director of the Suicide and Emotion Dysregulation laboratory.

State laws regulating handgun ownership are associated with lower suicide rates

by Michael D. Anestis, Ph.D.

 

As the director of the Suicide and Emotion Dysregulation lab at the University of Southern Mississippi, I spend a good deal of time researching risk and protective factors for suicide, both in the military and civilians.  I find the work rewarding, but at times I worry that the science we conduct in our lab lacks a voice capable of reaching a broad enough audience.  Generally speaking, loud voices are not how science works - and that's not always terrible - but there are situations in which a greater reach would be useful.

The other day, several of my students and I had a paper published in the American Journal of Public Health and I believe this paper represents one of those times when a loud voice is necessary.  Our paper addresses a controversial topic: legislation that regulates handgun ownership.  Conversations on this topic almost always turn into emotional conflicts driven by political views - many feel strongly on this issue - but my hope is to keep the conversation focused on the data, as I think they tell a very clear story independent of personal views.

In this paper, we wanted to clarify the relationship between firearms legislation and suicide.  To do this, we looked at three specific state laws regulating handgun ownership: (1) requirement of a permit to purchase a handgun, (2) requirement of a license to own a handgun, and (3) requirement to register handguns that have been purchased.  One concern we had going into this project was that individuals who oppose any legislation regulating handgun (or other firearm) ownership would accuse us of bias and dismiss our findings, arguing that we pushed the scales in the favor of our results.  To guard against this, we selected the three laws mentioned above by consulting the website of the National Rifle Association Institute for Legislative Action (NRA-ILA), which tracks these specific laws on a state-by-state basis.  Our thought was, if the NRA finds these laws important to track, they could not argue against their selection.

We had three specific hypotheses.  Using data from 2010 (the most recent available data at the time we were extracting it), we believed that:

1. States with these laws in place would have lower overall suicide rates (individuals per 100,000 who died by suicide), lower firearms suicide rates, and a lower percentage of suicide deaths resulting from firearms, even after accounting for the effects of poverty and population density
2. The relationship between the laws and overall suicide rates would be indirect through the percentage of suicide deaths resulting from firearms. 
3. States that implemented any of these laws during the time period for which data were available would exhibit decreased suicide rates in the years following implementation

Before reporting the results from those three questions, we noted some starting numbers

	States with 9 Highest % of Suicides Due to Firearms	States with 9 Lowest % of Suicides Due to Firearms
Population (% of Nation)	31,001,858 (10.0%)	91,090,901 (29.5%)
Suicide Deaths	4,252 (11.1%)	8,685 (22.6%)
Firearm Suicides	2,772 (14.3%)	2,906 (14.9%)

As you can see from that table, there were more than 60 million more people in the 9 states with the lowest percentages of suicide deaths resulting from firearms relative to the 9 states with the highest percentatges, but only approximately 130 additional suicide deaths by firearms.  These states were underrepresented in overall suicide rates.

But what about differences at the state level?

As you can see, here again the results are clear.  States with such laws in place exhibited substantially lower suicide rates - overall and resulting from firearms - than did states without such laws in place.  These tables, however, did not account for poverty and population density.  So what happens when we factor those variables in?

	Statewide Suicide Rate for 2010			Statewide Suicide by Firearm Rate for 2010			Statewide Proportion of Suicide Deaths by Firearms for 2010
	R2	F	pµ2	R2	F	pµ2	R2	F	pµ2
	.44			.50			.52
% of State Below Poverty Line		.87	.02		.59	.01		10.34**	.18
Population Density		2.35	.05		2.89	.06		5.24*	.10
Permit to Purchase Handguns		23.79***	.34		27.20***	.37		16.43***	.26
	.19			.28			.43
% of State Below Poverty Line		.26	.01		4.25*	.08		18.11***	.28
Population Density		4.47*	.09		4.30*	.08		5.65*	.11
Registration of Handguns		2.08	.04		4.62*	.09		6.28*	.12
	.29			.31			.41
% of State Below Poverty Line		.13	.00		3.99	.08		17.10***	.27
Population Density		4.03	.08		5.07*	.10		7.54**	.14
License to Own Handguns		8.99**	.16		6.86*	.13		4.52*	.09

Only the effect of registration laws on overall suicide rates became non-significant, meaning that nearly all of our effects still held.  Most importantly - and I know this sounds technical - but pay attention to the "partial eta squared" values.  These are measures of effect sizes, which tell you how powerful a relationship is.  Values above .16 are considered large - and those are rare in social science research - and yet you'll notice several of ours are well above that.

What about our second question?  We ran a series of analyses referred to as test of indirect effects and found that all three laws had significant total effects on overall suicide rates and that both the registration and license laws had significant indirect effects through the percentage of suicide deaths resulting from firearms.  This could mean one or more of several things: individuals in states with these laws attempt suicide less often, attempt using less lethal means, or have fewer handguns in their homes.  Regardless, the findings indicate that the laws work by reducing the frequency of death using the most lethal means for suicide.

And what about question #3?  Unfortunately, very few states had any changes in these laws during the time period for which we had data.  This prevented us from running the types of analyses I would prefer to run and you should thus consider the data below somewhat preliminary.  In 2003, California and Maryland both implemented laws requiring a license to own a handgun.  Notice how their suicide rates changed following implementation:

	United States	Yes License	No License	California	Maryland
% Change in Suicide Rate from 2001-2006	3.8%	0.8%	2.9%	12.8%	0.6%
% Change in Suicide Rate from 2001-2003	0.9%	-4.6%	0.3%	17.4%	5.7%
% Change in Suicide Rate from 2003-2006	2.9%	5.8%	2.6%	-3.9%	-4.8%

As you can see, after Maryland and California implemented license laws in 2003, their overall suicide rates declined whereas all other categories saw increases.

So what's the take home message here?  It appears that handgun legislation could have a robust role in reducing overall suicide rates on a large scale.  It also appears that this is likely to exert its effect by reducing the percentage of suicide deaths that result from firearms, which in turn is associated with overall reductions in suicide.  Lastly, although the data were limited, it also appeared that, in the years following implementation, states that instituted one of these laws saw a decrease in suicide rates even as the rest of the country saw a continued rise in suicides.

Legislation won't solve everything, but it doesn't have to solve everything to be important.  Suicide is a catastrophic health care outcome.  If we are serious about addressing it, we need to be able to have open conversations about the tools available to us to do so - even when those topics can lead to strong emotional responses.  I encourage each of you to closely consider the data presented here.  Folks who do not like these numbers will likely raise concerns that they suggest that the government violate freedom - the centerpiece of our country.  I would disagree with that assertion and would counter with the notion that suicide prevention is very much an American virtue and that, given increased rates of suicide in our servicemen and women in recent years, concerted efforts to reduce suicide through all means available are highly consistent with the moral compass of our nation.

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Dr. Mike Anestis, Ph.D. is the director of the Suicide and Emotion Dysregulation lab and the Nina Bell Suggs Professor of Psychology at the University of Mississippi.

 

I would note that the views expressed in this piece are my own and not of my employer or anyone else.

Post #2 in the Discussion of the Evidence Base for Music Therapy in the Treatment of Mental Illnesses - Reply by Music Therapy Maven founder Kimberly Sena Moore

A few days ago, I posted an initial article from a planned discussion about the evidence base for music therapy in the treatment of mental illnesses.  I received an invitation from Kimberly Sena Moore, who runs the Music Therapy Maven blog, to have a dialogue on this issue after I had a back-and-forth with some folks on the Facebook feed for Ben Folds on this issue.  Below is her reply to my initial post (click here to read my article).  As I noted before, Kimberly and I encourage readers from all perspectives to post their thoughts in the comments section.  One of the many things I appreciate about this exchance is the cordial and respectful tone and I'm hopeful readers can keep that momentum going.

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Musings on the State of Music Therapy Research: Strengths, Challenges, and Future Directions

by Kimberly Sena Moore

 

Earlier this month I invited Dr. Michael Anestis, a clinical psychologist and researcher, to share his perspectives on music therapy research. By his own admission, his area of focus is mental health research—which omits the medical, rehabilitation, developmental, wellness, and preventive areas of focus in music therapy research—but I felt he had fair and valid points that I am sure are not unique to him. So I asked Michael to share his thoughts on the Music Therapy Maven (link), following which I would write a response.

 

I am approaching my response from a couple of different perspectives. First is as a researcher. I have spent the last several years seeped in research, music therapy and otherwise, reading, analyzing, critiquing, and having conversations about the current status of our research literature and directions it seems to be heading. The second is as a music therapy advocate. It is a perpetual challenge in our field to disseminate and share our knowledge in a way that is accessible and understood by non-music therapists. The sentiment that “oh, you’re a music therapist, isn’t that nice?” can extend to our research. I would like to think that this perception is shifting, especially as our understanding of music’s influence on brain and behavior function continues to deepen, and I feel dialogues like this can go a long way towards advocating for our profession and its research.

 

In reading Michael’s post, his primary concern seems to be that our mental health research does not meet his (and others’) definition of having a strong evidence base. These characteristics include having multiple large trials, randomly controlled trials, reporting long term effects, and clear intervention reporting with a transparent description of interventionist training and an intervention manual. Furthermore, he is wary of music therapy’s ability to treat mental illnesses (which admittedly I am to, but I also don’t feel any one type of therapy—drug, verbal, cognitive, creative or otherwise—can alone “treat” mental illnesses, but that’s another conversation...).

 

I feel we should first acknowledge and feel proud of what the music therapy profession has accomplished research-wise. Our early leaders made an intentional effort to focus on developing a research base and we have accumulated a large body of literature in our almost 65-year history. Furthermore, we have accomplished this in spite of some real challenges. One of those challenges is numbers. Although our profession shows steady growth, we are still just shy of having 6,000 board certified music therapists in the country. And how many of those are conducting research? Furthermore, we are a broad field that works across multiple ages, treatment domains, and diagnoses. Although an individual music therapist will not practice that broadly, our collective body of literature is spread thin between the mental health, medical, behavioral, developmental, educational, wellness, preventive, and neurorehabilitative fields.

 

All this is not to provide excuses, but to acknowledge that, yes, we have had challenges and there are some very real areas in which we can and need to improve our research output. We need to continue our efforts to build a stronger base of evidence. Part of this relates to the criteria Michael laid out, such as incorporating larger Ns, conducting multisite studies, and reporting long-term effects. But that is also not the only criteria through which to judge a body of evidence. Evidence is also strengthened by conducting quality research that is intentionally laid out, theory-based, and transparent.

 

Below are 5 ways that I feel that music therapy research could be strengthened and pushed to the next level. As you may glean, I don’t feel the answer lies in jumping to large, randomly controlled clinical studies. Though these are an important form of evidence, I feel we also need to work on improving the quality and depth of our research, leveraging what has been done in the past, and building on the larger literature base. These ideas are not unique to me as other music therapy researchers are writing, producing, and discussing these. They also may not be the ONLY ways to improve our output. But I do feel they warrant mention and serious consideration.

 

1) More Music Therapy-Focused Systematic Reviews

A systematic review is like a super-strength literature review. There are many different types of systematic reviews (e.g. meta-analysis, meta-synthesis, Cochrane review, narrative synthesis, and more), but they share common features, such as creating a clearly defined research question and conducting the review in a methodologically rigorous way. The intention of a systematic review is not only to review the literature on a given research question, but to synthesize the results and use that synthesize to make informed, evidence-based decisions regarding clinical treatment and future research directions.

The appeal of conducting systematic reviews in music therapy is that it allows the researcher to leverage research already completed, then combine and synthesize the results, allowing for the possibility of, among other things, the creation of new knowledge or a more clearly understood grasp of music therapy intervention efficacy. In other words, it builds new evidence based on what has been done before.

For more information about systematic reviews, the upcoming issue of the Journal of Music Therapy will include an article I co-authored defining and describing the process to conduct a systematic review (Hanson-Abromeit & Sena Moore, in press).

 

2) Conducting Translational Research

Translational research is that which takes information from basic science research and translates it for practical, clinical study or use. With music therapy, this may involve, for example, taking research from the music perception and cognition literature and using it to inform the creation and/or study of a music therapy intervention. As with systematic reviews, part of the appeal of conducting translational research is that it allows one to leverage previously existing information. Furthermore it builds knowledge from the bottom up as the foundational framework is based in scientific evidence.

Click here for more information on translational research.

 

3) Creating Support with Theoretical and Conceptual Frameworks

As I understand it, theoretical and conceptual frameworks are very closely related and there is not a single agreed-upon definition for either. Ultimately, though, each relates to using the existing literature to support a line of inquiry by identifying the research variables and relationships between them prior to conducting the study. Thus the researcher has identified what is needs to be studied or measured and, more importantly, why. In music therapy-speak, this is similar to the difference between choosing an intervention or song because you think the client will like it or it will be “fun” and choosing a particular intervention because it is the most appropriate for a given client need at that time. Developing a conceptual framework is time-intensive—from personal experience it takes a lot of reading, writing, synthesis, processing, dialogues, and a willingness to be patient with the process—but ultimately it will lead to higher quality research due to the depth involved in developing the framework.

Click here to read more about the importance of conceptual and theoretical frameworks.

 

4) Engaging in Collaborative Research

As indicated earlier, the music therapy profession has a challenge with numbers. There are almost 6,000 board certified music therapists in the state—much less than many other healthcare and education professionals, I imagine—and a small percentage are trained researchers. Plus, to state it simply, the academics in our field have the knowledge of research and research process, but the clinicians in the field are working with the clients. It makes sense, then, to combine forces and develop more collaborative clinician-academic research projects. I have started to see more collaborative music therapy research occurring and expect more will happen in future years. What’s the benefit of encouraging or promoting this type of research? In addition to the benefits of working with an interdisciplinary research team where each person brings his or her own sets of skills, experiences, and resources, conducting collaborative research allows the possibility for more research to be conducted as it opens the doors for non-academics to participate in research.

 

5) More Transparent Intervention Reporting

Music therapy is a complex profession, as are other therapies that work with human behavior. In these fields and others there is a call for more transparent intervention reporting. What does this mean? It means that researchers are being called to describe any treatment intervention in an explicit and detailed fashion. In music therapy research this means detailing not just how the music and/or music experience is facilitated (e.g. tempo, melody, lyrics, instruments, intervention steps), but also any elements of therapist effectiveness. The benefits of incorporating explicit intervention reporting is that it will accomplish not only a real opportunity to replicate studies, but also the ability to break down the music therapy treatment and analyze exactly what was contributing to client (or study participant) change.

Click here for more information about the importance of transparent music therapy intervention reporting.

Conclusion

The song “We’ve Come a Long Way Baby” comes to mind when I think about music therapy research. We HAVE come a long way in our 65-year history, but we’re also not finished. There are some real and significant ways in which we can improve the quality and depth of our research output and continue to develop a strong base of evidence. I am one of many who are having these conversations and making these changes. If you have ideas or suggestions to contribute to this conversation, please share them in the comment section below.

Resources and References

Center for Clinical and Translational Sciences (n.d.) What is Translational Research? Retrieved from http://ccts.uth.tmc.edu/what-is-translational-research" target="_self">http://ccts.uth.tmc.edu/what-is-translational-research”>http://ccts.uth.tmc.edu/what-is-translational-research

Hanson-Abromeit, D. & Sena Moore, K. (in press). The systematic review as a research process in music therapy. Journal of Music Therapy.

McGaghie, W. C., Bordage, G., & Shea, J. A. (2001). Problem statement, conceptual framework, and research question. Academic Medicine, 76(9), 923-924.

Robb, S. L. (2012). Gratitude for a complex profession: The importance of theory-based research in music therapy. Journal of Music Therapy, 49(1), 2-6.

Robb, S. L., Burns, D. S., & Carpenter, J. S. (2011). Reporting guidelines for music-based interventions. Journal of Health Psychology, 16, 342-393.

About the Author: Kimberly Sena Moore, MM, MT-BC is a board certified music therapist and a Ph.D. Candidate at the University of Missouri-Kansas City, where her clinical and research interests center on music therapy and emotion regulation development in neurodevelopmentally at-risk children. Through her role as Regulatory Affairs Associate for the Certification Board for Music Therapists, she is involved in state-level advocacy, legislative, and policy issues affecting music therapy practice. Online, Kimberly co-hosts the Music Therapy Round Table podcast, and blogs at Your Musical Self for Psychology Today and Music Therapy Maven