There will come a point in our lives when we must become advocates for the health of our loved ones. Navigating the world of healthcare can be confusing, complicated, and emotional, even for the most informed. Bonnie Friedman, author of Hospital Warrior: How to Get the Best Care for Your Loved Ones, understands these challenges first-hand after spending more than 24 years advocating for her husband through 14 hospitalizations. In her podcast, Hospital Warrior: Advocates and Experts, Friedman helps others learn how to be champions for their loved ones, armed with guidance, support, and knowledge. Friedman recently interviewed Voi’s Chief Science Officer, Bill Hudenko, Ph.D to talk about advocacy from a suicide risk standpoint, and discuss the use of technology in suicide prevention. Hudenko shared his expertise on how technology is changing the risk-assessment landscape, and offered advice to anyone concerned about a loved one who might be at-risk for suicide.
(This interview has been transcribed from the Hospital Warrior: Advocates and Experts podcast hosted by Bonnie Friedman, with edits for length and readability.)
Bonnie Friedman (Friedman): It’s been said that suicide is a permanent solution to a temporary problem. Yet, it's one of the leading causes of death in the United States. For all the advances we have seen in healthcare, in so many areas, detecting someone who's considering suicide still remains a major challenge. Can you talk to us about the prevalence of suicide and what's going on with risk assessment?
Bill Hudenko (Hudenko): Suicide is an enormous problem. Not only is it one of the leading causes of death in the United States, but rates are at a 30-year high. We’re able to predict fairly well whether someone is at long-term risk. However, historically, it’s been extremely hard to predict near-term suicide risk, which is when someone might commit suicide within 72 hours. Very often, the window in which people might consider hurting themselves is almost 10 minutes, so trying to capture that window is extremely challenging.
Friedman: That 10-minute window you described is breathtaking - to think that 10 minutes can truly make the difference in time between literally life and death. Why are suicide rates so much higher now, why is it an all-time high, and what's going on that is driving those sort of numbers?
Hudenko: There are a lot of different factors. Much of the way we think about suicide in clinical psychology has to do with people coming to the conclusion that there's no other way out. Therefore, a whole host of situations lead people to think that there's no option, such as dealing with financial hardship, or difficult cultural and social factors around discrimination or exclusion. I think there are many social trends right now that possibly reflect this increase we're seeing in the US right now.
Friedman: Talk to us if you would about this 10-minute window. What enables you to be able to define it so precisely as 10 minutes, and what is the avenue into that 10-minute space in order to be able to make a difference?
Hudenko: Generally, when people are at real risk of self-harm, they’ve often been thinking about it for some time. We call that “suicidal ideation,” which becomes more serious the more they plan-through taking action. It's often the case that when someone is just about to commit suicide, there's this approximately 10-minute decision-making window where they are at extreme risk. So obviously, as you say, it's breathtaking to consider how we can effectively intervene during that window. The first step is to identify people and figure out when they're at both long-term risk and real near-term risk.
Friedman: Are there some warning signs or other indicators that are the real red flags for imminent risk?
Hudenko: We really promote the idea of universal suicide risk screening, which is the practice of automatically screening when a person comes in and sees anyone in the health system. We have a tool, Voi Detect, that assesses for risk within only two minutes, and from that evaluation, it's about 94% accurate relative to a psychiatrist’s judgment. We automate that process, and that screening gives us a 72-hour view into someone's life, which we consider to be the first point of monitoring and intervention.
Friedman: So you have a tool and you can put it in the hands of a clinician in the hospital setting, or even in the doctor's office for your regular yearly check-up. This tool would give a very accurate indication of how vulnerable a person may or may not be; is that correct?
Hudenko: Yes, we are proposing its use in a lot of settings, including in the military, emergency departments, and in primary care facilities. The tool replicates clinician judgment, which is really the gold standard in understanding risk. I think we’re in a very exciting time right now; we now have the tools and the technology to leapfrog our capabilities around near-term suicide risk assessment. I’m all about figuring out how we can do this better - and I think we already have a way to do it better. The algorithm our tool uses allows us to continuously improve the prediction, so that we get better and better at catching people before they might try to take their lives.
Friedman: So the more data you’re able to collect, the more rich the data becomes, and therefore, the more effective and useful the tool grows to be. Can you give us an idea of what kinds of questions go into the tool? What types of things does this tool prompt in terms of question or conversation?
Hudenko: The questions are really simple. We ask them things like: the amount of pain that they're in; their wish to live and their wish to die; their substance use; and we also collect things like demographic information that we know might increase or decrease their risk. The tool that we use on our software platform was developed by some researchers at the University of Vermont, who extensively tested these items that psychiatrist typically ask patients. We knew that it was critical to have a really simple way to assess risk and do it quickly.
Friedman: Do you find people are truthful and are they honest about their current conditions, so to speak, that they will tell the doctor or clinic and what they're really thinking and feeling in the moment?
Hudenko: We've seen through research that up to a quarter of people who take a suicide risk assessment in an emergency room setting may try to pretend that nothing's wrong, even when there is. As a result, when we create a test, we consider what's called “face validity,” which is how easily someone can “dupe” the test. Our tool has relatively low face validity so that it's more difficult for someone to try to “fake good.” We're always worried about missing people at risk, but these advances in technology, where we automatically assess for risk over long periods of time, can help solve some of these problems.
Friedman: Are there populations that seem more at risk than others and are in greater need of the risk assessment as a whole?
Hudenko: Yes, this is part of what we do when we profile people for increased risk. For example, men are much more likely to complete suicide attempts than women, but women are more likely to attempt suicide. People who are going through a gender transition are particularly at risk; certain parts of the elderly population are at risk; and we know that people living with psychiatric conditions like depression, bipolar disorder, and schizophrenia are also at higher risk.
Friedman: Are veterans also a group that has a high risk of suicide?
Hudenko: Yes, absolutely. There's tremendous applicability here to veteran populations, because about 20 veterans a day die by suicide. A lot of it has to do with problems associated with veteran care when veterans return back to the United States. Even if supports are in place - like at a local VA - unfortunately, many people just get put back into their rural environments, where they have almost no support and they may have co-morbid conditions like post-traumatic stress disorder that might increase their risk.
Friedman: You mentioned earlier that you were working on a next-generation, another iteration of this technology. I'd like you to tell us a little bit about the complementary approach.
Hudenko: Our company is Voi.com. The company name [Voi] was developed with the idea that we view healthcare as a voyage. Our objective as a behavioral healthcare company was to try to help people navigate that voyage and to find quicker, better, and more affordable ways back to health. Voi Reach was developed out of the idea that suicide assessment - which we do with [our first product] Voi Detect - is a critical need, but unfortunately, it's not enough. Once we identify someone is at risk with Voi Detect, what do we do? How do we keep these people safe? We found that very often it’s because of the smallest things. When you talk to someone who almost made an attempt you say: “What was it that the kept you from killing yourself?” You hear stories where people will say things like, “I went to the store and someone smiled at me,” and that was enough.
Those powerful stories made us realize that the strongest thing that keeps people alive is connection. It doesn't even have to be a connection with someone you know. Connections with other people give us meaning; they give us a reason to live.
We created Reach to build a natural support network around a patient, at the time of discharge. We created this network of people that the patient invites, made up of friends, family, clergy - really anyone - and then we give them a behavioral health coach. Unlike traditional models, that health coach helps the natural support network. The health coach reaches out to those people and teaches them things like what to say when someone is suicidal; what are things you don't say; and how often should you reach out. We think that network is going to be the biggest advance in safety as we move forward.
Friedman: So this is an online community - is that what you're describing?
Hudenko: It's an online community of people’s natural world, and, in addition to their network, we supplant a professional who can help guide that person. We also give immediate access to crisis help, directly through the app.
Friedman: You mentioned early on that often suicide results when people can't think of another solution. Is this a way in to reach that part of the brain that still functioning on a rational level?
Hudenko: I would say so. There’s an interview with someone who survived jumping from the Golden Gate Bridge, who said that the one common element across all who have similarly attempted suicide is regret. In the moment that they jumped, every single person wish they hadn't. I just think it's so powerful because again, it teaches us that there is a way to reach most people. At Voi, we’re all about identifying and capturing moments when people are accessible and when they are at risk, and then giving them that hope that keeps them alive.
Friedman: That's such a powerful message and I'd like to use it to jump to another aspect of prevention, and that is for the advocate, for the person who has a loved one or friend that they're worried about and either has heard that person say things that are alarming or suspects that because of perhaps what's between the lines the person may be considering suicide. What kind of advice do you give to that individual the friend or loved one who's worried about someone else?
Hudenko: If we're hearing people talking about ending their lives, we should take it seriously. We should act. People are commonly concerned about whether they should ask or say something, because they’re worried if they do, then the person may do something or get the idea. That's just absolutely false. In fact, asking people usually increases their safety; it doesn't usually plant the seed of an idea. If you are concerned, you should ask why someone is thinking about hurting his/herself. As a clinician, I ask people why they want to stay alive, because it challenges the person to think about what he/she has to live for right now. When people don't have an answer to that question, it increases my worry because I want them to feel like there's something to live for. We tell people to look for whether somebody has a concrete plan or means, like whether they have guns available to them or other ready means to commit suicide — that’s a significant risk. If someone is giving things away or giving other indicators that they're moving through with their plan, that signifies even more risk. If you are in a situation where you feel really worried about someone, don't keep it to yourself. Seek professional help. Reach out.
Friedman: What does that mean: “seek help?” What do you do? You’re sitting with someone in your house - a member of your family - and you're worried sick that they're going to do something to harm themselves. What do you do?
Hudenko: A lot of people don't know that there is a federal law in the United States that allows people to be involuntarily committed to a hospital.
Friedman: The Baker Act.
Hudenko: Yes. If someone is imminently at risk of harm to themselves or to others, you can call 911. [Medical help] will come, evaluate that person, and potentially take them to the hospital to make sure that they're safe and stabilized. If it's really imminent, there is a course of action that can help that person to stay safe. What becomes more difficult is when there's a borderline case, like when someone is talking about harming themselves, but doesn't really seem to be an imminent risk. Under those conditions, I recommend people encourage that person to talk with a professional. One of the best things you can do to support someone is just reduce the barriers in connecting them with a professional. Help them identify a clinician or expert they can speak with, set up a phone call - things like that. You don't want to be in a position where you didn't act and then you regret it.
Friedman: So it’s those concrete steps I think I hear you identifying — not just saying you have so much to live for, or let's talk about some good things in life, but rather very specific things that can be done, e.g. let's find a professional who you can talk to, let's set up a meeting with someone, or if necessary, as you said, call 911. But don't just talk about it; focus on the concrete steps that might be taken. Am I hearing that correctly?
Hudenko: Absolutely. The idea is that no one should feel like it's their responsibility to keep someone else alive. And yet, we do feel that burden and responsibility for people who we care for. There's only so much you can do for an adult. If it's a child, you can take a lot more action, but for an adult, the best you can do is to get them help.
Friedman: Well, that's a strong message. The idea of helping somebody get help is a powerful message.
[Listen to the full interview here.]