Scott Webb (Host): Suicide is one of the leading causes of death in the U.S. According to the Centers for Disease Control, suicide has become the second leading cause of death among Americans under the age of 35, as reported in 2024. Here with us today is behavioral health specialist from Summa Health, Karen Hogan. She's the Associate Chief Nursing Officer who manages inpatient and outpatient care. 

This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Karen, it's nice to have you here today. We're going to talk about an important topic, suicide, prevention, treatment. But I think before we get there, I just want to have you talk about some of the most common conditions that are associated with suicide.

Karen Hogan: Mainly what we see with patients who present with potential for suicide or pose suicide, attempt, often they will have mental health conditions such as depression, substance use problems and addictions, bipolar disorder, especially bipolar that manifests itself with depression, schizophrenia, and certain personality traits.

I always say that, when it comes to personality disorders, there's no pill for that. And that's why treatment is so important. But certain personality traits that often exhibit like mood changes and has results in poor relationships, conduct disorders, anxiety disorders, and then of course there's always a cognitive decline in individuals that might cause a risk of suicide.

The other thing that can cause people to even have the consideration of suicide is someone who's living with physical health conditions, especially with pain. Some folks have traumatic brain injuries and the limitations that that brings in their daily life. The other thing is access to lethal means. For example, firearms and drugs. Or if they've had a prolonged period of stress, if they have difficulties at work, if they have relationship problems like bullying, harassment. And then, of course, the financial stresses that come with unemployment; stressful life events like rejections, divorce, and those kinds of things.

And then, one major thing is exposure to another person's suicide, so either a friend, a family member can also lead to individuals thinking about suicide. And if they have it in the family history, it definitely puts them at risk.

Host: Yeah. You used the word risk there, and that's kind of how I wanted to follow up and just find out from you, get a sense like are there some risk factors that increase the chance of someone becoming suicidal?

Karen Hogan: Oh, yeah. And I kind of categorize them in different areas. You know, individual risk factors would be things like a previous suicide attempt or history of depression and other mental illnesses. And as I mentioned, some of the physical issues and then relationship risks, things like bullying, family history of suicide, loss of relationships, and even social isolation. And then, community risk factors would be things like lack of access to good mental health agencies and healthcare, suicide clusters in specific communities, community violence, historical trauma, discrimination, and those kind of things.

Host: Yeah. Wondering, you know, when we think about families, friends, you know, in terms of identifying the early warning signs of suicidal thoughts or behaviors, like what should we be on the lookout for?

Karen Hogan: Well, you really want to listen because many times people that are thinking of suicide might say things like they just want to die, especially with folks that have chronic health conditions, might just want to end it, and not have to go through all of the pain or the disability of other health conditions. They might also talk about certain kinds of great guilt. They may feel shame for something or feel like a burden to others. As far as how a person's feeling, we want to look for hopelessness, people that might not have a reason to live. They're just constantly sad, constantly negative, get agitated easily, might have a lot of rage.

Or then from a behavioral standpoint, you may see them giving things away because they want to say goodbye, withdrawing from friends, taking certain kinds of dangerous risks like driving, you know, extremely fast, being very careless, having a lot of mood swings. And then, of course, watching, eating and sleeping habits, and then possibly using drugs and alcohol.

Host: Yeah. And I see what you mean that having our eyes open, having our ears open, really watching, you know, family members, friends that were concerned about really listening to them. Let's talk a little bit about some of the therapies, the treatment if you will. Like what are some of the most effective evidence-based therapies for suicide prevention, you know, that are, let's say, currently recommended by mental health professionals?

Karen Hogan: So, the most effective, when we look at the professional literature, it really brings us back to the basic cognitive behavioral therapy, which really is looking at a person's thinking and behaving. And cognitive behavioral therapy has been around for several decades. I call it talk and action. So really, cognitive behavioral therapy identifies and it actually challenges the negative thought patterns in a person's behavior and their responses to certain things.

Another form of cognitive behavioral therapy is a therapy that was developed around the late 1990s and early 2000s, and has been very successful in helping people to deal with especially chronic suicidal thoughts, and that is what's called dialectical behavioral therapy, which emphasizes acceptance and change. You know, teaching coping mechanisms, and really it revolves around emotion regulation, the tolerance for distress, interpersonal effectiveness, and mindfulness. And we hear a lot about mindfulness in our culture, but really learning what mindfulness means. 

Host: Yeah, you're so right. In hosting these, mindfulness comes up a lot and I sort of nod my head, you know, when I'm having these conversations, but maybe you could explain a little further. Like, what does that really mean in practical terms, especially for folks who have suicidal inclinations or suicidal thoughts?

Karen Hogan: So, what a person would really, work on with their therapist would be identifying their cognitive distortions, you know, where is my thinking incorrect? And being able to verbalize what they're thinking. So in this DBT, you know, it really must be a trustful relationship and being able to share thinking that is identified as a bad thinking, however the person sees it, you know, negative thinking. So, identifying those thoughts, but then being able to set goals on how to stop the thinking and focus on the here and now. And I think for many of us in a culture that we live in, everything in everybody is in a rush. We're thinking about the next thing that we need to get to. We're thinking about a hundred things at once, but being able to stop that and say to oneself, "I'm doing this now because it is going to be better for me," and then putting those thoughts into action.

Host: Yeah. Yeah. It is so difficult, Karen, you know, to just try to live in this moment, right? This moment, right here and now, and not think about all the other hundred things, groceries and laundry and, you know, all these other things we have.

Karen Hogan: That we're always worrying about.

Host: Always, right? All of us, because we're all humans, of course, right?

Karen Hogan: Exactly.

Host: Yeah. So, let's talk along the lines of treatment and recovery. Let's talk about the role of medications. , maybe an antidepressants, you know, in the treatment of patients who are at risk of suicide.

Karen Hogan: So, of course, being in the field of psychiatry, I'm always attuned to what medications are coming out, what the indications are, what are some of the warnings, and I know some of the antidepressants and anti-anxiety medications have had a lot of advertisement on TV. And then, I always say at the end of the advertisement, you hear a hundred things that are wrong with the medication. And I think to myself, why are you even advertising these medications?

Host: Yeah, those are the side effects. Yeah.

Karen Hogan: All the side effects. And there are side effects. That's why if you find a psychiatrist, a primary care doctor, and a therapist to help you with this thinking, you've got to trust that person. And we're always looking for the side effects as well as the improvements in mood.

So, there have been the discussions around the increase in suicidal thoughts around some antidepressants. I always try to explain that to people as, yes, that can happen, but what, really is going on is that their moods sometimes improve to an extent that they're now able to actually focus on whatever the plan is. So, you have to be very cognizant of that as a provider, but also as a family member, knowing that you've got to watch when a person seems to be much happier when they were extremely depressed. You want to explore that a bit. You want to find out what's going on. Because that could also mean that they have maybe come to terms and decided what they're going to do. So, there's always things to look for, both positive and negative, but that's where a trusting relationship is so important with your providers. I mentioned, both psychiatrists, primary care providers, as well as therapists. As most people know, primary care providers are the, probably the highest prescribers of psychiatric medications because the provider that the individual has seen for a long time trust.

One of the things that is real important is that primary care providers, either nurse practitioners, physician assistants or physicians making sure that they stay as current as possible, but also, you know, trusting psychiatrists because they're constantly studying new medications. A lot of times they're involved with research on certain medications. And then, the person also needs a therapist because it's not just about taking a medication, it's also working through what's in your mind.

Host: Yeah. It does seem that that's a common thread that I've had in these conversations, that it really is a team approach. It's family, friends, it's the patient, it's the, you know, primary care psychiatrist, everybody working together, speaking, listening, all of that.

I want to talk about survival, you know, and folks who have survived. You know, when it comes to the mental health professionals really addressing their needs of someone who's survived, maybe you can take us through that.

Karen Hogan: So when someone has survived an attempt, there's a lot of things that we have to look at. First of all, we need to address the trauma of the experience as well as the trauma-- so, it's the psychological trauma, but also the trauma that could have occurred physically, because I've known patients throughout the years who have used what one would consider the most lethal, you know, a firearm and then survived it, but were left with facial disfiguration and things like that. So, you've got to help them to be able to cope with all of that.

I always, you know, think of the hierarchy of needs, because that's really the most basic thing, is the physical survival. But then, of course, wanting to make sure that we're informed about all trauma that they have experienced that has led to this. And a lot of times, and I would say the majority of patients and individuals who have had a suicide attempt but have survived, the majority have some kind of trauma in their background. And that's why I believe that practicing trauma-informed care is probably the best thing a clinician can do for someone who has survived, because then you become aware of what the underlying issues are and then help them with the cognitive therapy that they need to be able to survive it.

The other piece that's really important because most times, if someone has survived a suicide attempt, they most times will come to an inpatient facility. And one of the things that we always make sure that we work on with the patient is to have a safety plan. Because there's going to be a time when they will be out, working or with family or even in isolation, but making sure that they have some kind of a safety plan that when they get these thoughts again, what is it that they need to do? And that's why we always include the patient because we can have a beautiful-looking, you know, plan, but if it doesn't work for the patient, it's not going to do any good.

Host: Right, right. If the patient's not going to even follow the plan, doesn't buy in, it makes it difficult, right? Yeah.

Karen Hogan: Exactly.

I'm sure, thinking about this, so there's like the initial sort of interactions with someone who survived a suicide attempt, but then the follow up, maybe you can talk about that when we think about the recovery process, if you will. What's the follow up look like?

Most of the time, someone who has survived a suicide attempt, it would be most beneficial for them to participate in an aftercare plan. So, we have intensive outpatient therapy here at Summa, and that usually involves three to five days a week for several weeks.

Karen Hogan: And that way, they're able to be assessed on a daily basis, but still be able to be out of the inpatient hospital. Additionally, it's important for them to be able to be with other people who have experienced things that might be similar. And that's always of course a great way to share what's worked for others and then they can add that to their plan, identify triggers, things that might set them off. So, we always want them to be connected immediately after hospitalization.

The other piece, I always try to encourage people to get involved in the community, whatever works for them. It might be their faith community, it might be some kind of a spiritual experience group for them. There's a program called NAMI, which is national Alliance for the Mentally Ill. And they have great programs for family members as well as individuals who have major mental illnesses. That's an ongoing resource for a lot of the people.

 There's a lot of suicide prevention programs. And I would definitely encourage individuals to find what works for them. I know that there are suicide prevention walks. Of course, September is Suicide Prevention Month, and I know that some of the local groups have what they call Out of the Darkness Walks. And it's good because they're able to celebrate those who have survived as well as families who are left without their loved ones. And it's a way to really engage in the community. So, it's really important that the community involvement is part of the recovery.

Host: Right. Yeah. And it really does feel, Karen, this is anecdotal at best because I'm just a lay person and not the expert that you are. But it really does feel like recovery, you know, there's such a variable. For some, it may be relatively quick. For some, it may be a lifelong process, right? It's a lifelong battle, a lifelong work being done by them. There's no blueprint for this. There's no template for this. There's no one-size-fits-all, right?

Karen Hogan: No, absolutely not. And you know, for those that have a co-occurring substance use issue, going back to their 12-step programs many times is extremely helpful. I've known people that have had family members who have engaged in some of these groups. You know, either Alcoholic Anonymous, or it could be Gam-Anon for those that have gamblers. So, it can either be for the survivor or the family. Those groups are very involved in supporting, but you just have to make sure, you know, just check the groups out.

Host: Yeah. I want to give you a chance here as we get close to wrapping up, maybe you can share some specific resources, hotlines, organizations, like where can folks go? Who can they call? What websites can they visit?

Karen Hogan: For emergency needs, we'd always dial 911, you know, if you need the help for emergent. But the other thing is that there is now a 988, it's manned by the Ohio Department of Mental Health and Addiction Services. If you text 988 or you can also chat online at 988 lifeline.org. And that's specific to help you with suicidal thoughts, resources a place for you to chat with someone and walk you through things.

The veterans also have a crisis line. You can text 838-255. That's 838-255. And that's for veterans when they are in crisis. Nationally, we have the Substance Abuse and Mental Health Services Administration. I call it SAMHSA. And they have a national helpline. Their number is 800-662-HELP, 800-662-H-E-L-P. For those that might be in emotional stress, because there's some kind of disaster, and we've had several of those this past year, but there is a disaster distress hotline, and that's an 800 number, that's 800-985-5990. So, there are many places to get help. Of course, your local emergency room, if it's an emergent issue and you need help right away. But you know, that's of course up to the individual and the family.

Host: Yeah. Well I know that we could speak for far longer than we have, you know, for the average podcast. Karen, I really appreciate your time, your compassion, your expertise today. Just want to give you a chance here, sort of final thoughts, takeaways, but what would be the message you would share with listen listeners who are struggling?

Karen Hogan: Okay. You know, that's a really good question because really if you are struggling with these thoughts, please don't be afraid to get help. You have a purpose. And let others help you find that. And so, never feel funny about asking for help because help is not that far away, as I mentioned with some of these phone numbers. And these places would keep all of your information confidential because we want you to be well. So, please don't feel funny about getting help.

Scott Webb: Yeah. That's so well said. You know, I think that, you know, I'm in my mid-50s, Karen, and it seems to me when I was younger, that mental health and having even a conversation like we're having today and encouraging folks to advocate for themselves and speak up, or family members and friends to speak up on their behalf, it seems like there was just a lot more stigma, you know, with all of this. And whether it was maybe COVID sort of unlocked some of the doors and conversations, I'm not sure, but it just feels like we can have this conversation now that it just feels safer to have this conversation and more and more folks are willing to step on their own behalf. Has that been your experience?

Karen Hogan: Yes. Yes, it has been. And there is something that, I remember, hearing through someone in AA who said, don't compare your insides with other people's outsides. And I think that's what we have done for so long. And of course, with social media, it always looks beautiful in somebody else's life, and we're sitting there, but be conscious of the fact that we're all vulnerable and something could happen to any of us. And I do think that COVID showed us that need others to help us to be successful and find purpose in life.

Host: Right. Yeah. Just always remind yourself that all those Instagram photos, as beautiful as they are, they all have filters on them, right? Our lives, our insides, as you say, they don't have filters.

Karen Hogan: Right.

Host: Yeah. Well, this has been such a beneficial conversation for me today. Just benefiting from, you know, speaking with you and your expertise. And I'm sure for listeners as well, we want folks, if they're struggling to, speak up, to advocate for themselves, to know that it's okay ,that there are, you know, trusted resources out there and help is available. So, thank you so much.

Karen Hogan: Thank you.

Host: And to learn more about Summa Health Behavioral Health Services, visit summahealth.org/behavioral or call 234-475-HELP. That's 234-475-4357.

And if you enjoyed this episode of Healthy Vitals, we'd love it if you'd leave us a review. Your review helps others find our educational content. I'm Scott Webb. Thanks for listening, and we'll talk again next time.