Suicide and Anxiety

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Featured Guest: Jami Socha, PhD, and Christina Laitner, PhD  

Objectives

• Understand the relationship between anxiety and suicidality.

Resources

• Helping Kids in Crisis: Managing Psychiatric Emergencies in Children and Adolescents, Kids in Crisis, pp. 1-11. (American Psychiatric Association)
• Parenting a Teen who has Intense Emotions: DBT Skills to Help Your Teen Navigate Emotional and Behavioral Challenges. (New Harbinger Publications)

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Transcript

Christina Cwyner:

Hello and welcome to Breaking Down Mental Health, a podcast series developed to educate all healthcare professionals on various mental health topics. I am Dr. Christina Cwynar, a nurse practitioner. I'm joined by my co-host social worker, Syma Khan and child and adolescent psychiatrist Dr. Heidi Burns. Dr. Burns has kindly offered to sit this discussion out so we can have two wonderful experts for our discussion today.

Today we are joined by Dr. Christina Laitner and Dr. Jamie Socha here to discuss suicide and anxiety. Dr. Laitner is a licensed psychologist and a clinical assistant professor in the Department of Psychiatry. She specializes in working with youth and families with complex psychiatric needs, including traumatic stress, anxiety and mood disorders, suicidality and non-suicidal self-injurious behaviors. Dr. Jamie Socha is a licensed clinical psychologist and a clinical assistant professor in the Department of Psychiatry. She works in the department's child OCD and anxiety disorder program where she specializes in evidence-based treatments for anxiety in children and adolescents. None of the speakers here have any conflicts of interests or disclosures.

We are excited to have you both here today. Let's start our discussion off today by dissecting the relationship between anxiety and suicide. How does having an anxiety disorder relate to somebody's suicide risk?

Dr. Jamie Socha:

I thought maybe we can start by defining those two things separately and then talk about how they're related. Quick refresher, seven primary anxiety disorders in the DSM-5. We have separation anxiety disorder, selective mutism, specific phobias, social anxiety disorder, panic disorder, agoraphobia, and generalized anxiety disorder, so quite a few there. Historically, OCD and PTSD have been an anxiety disorder category. However, conceptualizations evolved and they are now in their own categories in the DSM, but they're very anxiety-adjacent disorders so we're still kind of including those I think in our conversation about anxiety today.

The first point I wanted to make about anxiety disorders was our conceptualization of them as really being maintained by escape and avoidance. So people with anxiety disorders try very hard not to face the things that they are afraid of. Unfortunately, that robs them of some very important experiences like seeing what would happen if they did face it. Maybe their expectancies or predictions don't come true, they didn't need to use all those safety behaviors or they coped far better than they thought that they could. So that piece is also pretty important in connecting then to suicide risk. Some theories talk about this escape-driven behavior, maybe increasing vulnerability to contemplation of suicide. I think that's a good segue over to talking a little bit more about what we mean about suicide risk, how we define that.

Dr. Christina Laitner:

Suicide risk refers to the likelihood of an individual to attempt or die by suicide. The likelihood is estimated by assessing the presence of predisposing or precipitating factors and their interactions. Thank you, Lee Chao and Ballard 2022. I wanted to separate the idea of suicidal behavior and also just bring in non-suicidal, self-injurious behavior to the discussion using Posner's system of categorization right through the Columbia-Suicide Screener Scale. The suicidal ideation, thinking about suicide, thoughts about suicide ranges from passive all the way up through active with method, intent, and plan. And there's in between you can have someone who's actively thinking about it and has no intention, no method, no plan. We move on to we've identified a method and we have no intention, no plan. Active suicidal ideation, method, intention, no plan. I think acknowledging the continuum is important. This is not an all or nothing. There's very different intervention points depending on where you fall.

Suicidal behavior really can be defined as any step that a person has taken towards acting on a suicidal thought and for non-self, well, for self-injurious behavior, I just want to quickly make the point that there's self-harm behavior when a child does something to harm themselves on purpose does not necessarily mean it's suicidal. Of course you can self-harm for many other reasons, so I just wanted to separate that out.

Syma Khan:

Thanks so much for kind of sharing that overview, and I think it is really helpful to take that step back and think about both anxiety and the criteria for suicidal ideation or self-injurious behavior, and then how do we conceptualize those two things together. Because I think so often we're kind of assessing for things specifically, and so we really need to have that broad lens so we're not missing anything when we're engaging with youth in various settings and particularly in healthcare.

Dr. Christina Laitner:

I think it's also so important to your point, as I think we often talk about suicidality with major depressive disorder, knowing that a huge proportion of kids who do present with suicidality or self-interest behaviors is that is a major driver and there is that proportion of kids that's either not present or it's an interactive factor. So it's a really exciting opportunity to get to think about anxiety here at the forefront.

Syma Khan:

Yes, definitely. I think it's something that many of us who struggle with on a non-clinical basis, we all have those moments. So I think just thinking through where else do we need to be mindful about engaging and asking about anxiety and suicidal thoughts. Pivoting a little bit, thinking about youth that may experience anxiety as we talk about maybe not meeting criteria, sometimes youth don't meet the threshold for an anxiety disorder, but they may still be at increased risk for suicide. So how should healthcare providers assess for this or engage these youth?

Dr. Jamie Socha:

So I wanted to start by just reminding folks that a couple of years ago, the US Preventative Services Task Force came out with guidance that we should really be universally screening for anxiety disorders at ages eight and above. So screeners like the SCARED that stands for Screen for Child Anxiety and Related Disorders, really good one. It's for ages eight to 18. It has a parent and child version. So really helpful information that you can collect there. GAD-7, a really quick and efficient seven-item questionnaire, but in this process we're inevitably going to get kids who really kind of lump into three categories. They're going to have non-anxious youth who are barely reporting any anxiety symptoms. On the other end of the spectrum, we're going to see kids reporting quite a bit of anxiety, going to fall into that kind of clinical diagnostic category. And then we're going to get kids with elevated but sub-threshold anxiety.

And this can be a really hard group to know what to do with. So even just my quick review of the literature, I thought this was such a great question. They found sub-clinical anxiety symptoms are associated with an increased risk for suicide. So this is often in adolescents, the study that I had mentioned, twice the risk of teens reporting suicidal ideation within the past two weeks if they were reporting elevated anxiety symptoms, even if that did not meet criteria for kind of threshold anxiety disorder. So still really important to be screening for that and those kiddos who were reporting anxiety symptoms. I think I'm going to hand it over to Christina maybe to talk a little bit more about screening for the suicide piece.

Dr. Christina Laitner:

I think for the screening, I think it's all about early identification, and I want to be careful here. I don't think we're not saying a kid presented with sub-clinical anxiety is at heightened risk for suicidal behavior. It's one of those risk factors in the trajectory of things. So I don't want people to conflate those two things. It's actually quite different in terms of screening for suicidality. It's similar to what Jamie was talking about. I mean, again, I think here at the University of Michigan, many other major medical settings use the C-SSRS, and although it was first developed for adolescents and older, now there's a lot of evidence base for our six to 12-year-old kids as well. I think really our task is to incorporate it in any sort of healthcare screening the way we do any other questions, the way we ask kids about sleep, the way we ask kids about what they're eating. I think normalizing it for kids that these are questions that we ask to everyone is really key. That's where we're going to get the most yield for our questions.

Christina Cwyner:

I think along those lines, it's not only normalizing the question, but also preparing our staff and our parents for those conversations as well. Because not something like you or I grew up getting asked at six years old about suicidality. So it's something new for everybody and it's something that we've been working on in the hospital side is starting to educate our staff. And preparing patient facing, family facing materials so that we can start to assess suicidality universally in that younger group as well. So any thoughts about that?

Dr. Christina Laitner:

Well, yes. So I think what's so helpful is from the healthcare side, the more that we can provide scripts to our colleagues who this is not part of their daily work, I think a major thing that we get back is, "Well, if we ask them about this, we putting them more at risk. Are we going to put the ideas in their head? Is it going to be more distressing?" And we think about the seminal study from 2005 in which it shows that asking kids about suicidal ideation or suicidality does not increase the risk. And in fact, for those kids in this study who had maybe endorsed more like depression or distress, they actually found it relieving that someone was asking them about these questions. So it's sort of the opposite of our fears. And I think yes, it helps us identify more kids. And even for those kids who may be at that particular moment, it's not a pressing issue. Letting them know that there are adults in their lives with whom if that does become an issue that they can connect back to. We're really also trying to get the preventative effects here.

Christina Cwyner:

No, exactly. And I think as we move towards this universal screening of younger children, it's also important to remind providers and even parents because this podcast reaches both, as a healthcare provider, we're also potentially parents as well of how we frame questions and how we have those conversations. And just thinking about some recent conversations I've had with younger kids and it's like they maybe spontaneously said something like, "I'm thinking about dying." And then you're like, "Oh, tell me more about that." And they're like, maybe their response is, "You know what? I think about it a lot." "Okay, why? What is going on? What is that thought around dying?"

As you ask those maybe simpler, more direct questions, it's like, "Oh, I have a significant fear of dying. Not that I want to die." But kind of digging that out. And I mean, we also see this in the ER a lot, the younger kids coming in and maybe they've told mom and dad they want to die, but really, "It's grandma just died and I miss grandma and I want to be with grandma." And the way to do that is to die, but they're not going to harm themselves. They're grieving.

Dr. Jamie Socha:

If this is an okay segue?

Christina Cwyner:

Yeah, Go ahead.

Dr. Jamie Socha:

What you're talking about reminds me a lot of what we see in anxiety disorders in people who are afraid of dying. This can be a major theme in anxiety disorders. OCD, for example, has a subtype, sometimes I call it suicidal OCD, right? Where the obsession is about committing suicide. What if I commit suicide or what if I could become depressed and don't realize I'm so depressed and then I snap and I commit suicide? So a person could very much screen positive on a suicide screener if we're not asking those follow-up questions like you were talking about.

So I think one really important point, if you're working with or you're evaluating somebody and hearing those kinds of, usually it's peppered with doubts or what if questions and an OCD, we think about the difference between ego dystonic thoughts and ego syntonic thoughts. A person who's experiencing suicidal obsessions with OCD is experiencing them as ego dystonic, and that just means it doesn't fit with their true feelings and wishes or identity and values. That's why it's so distressing to them. A person who is experiencing true suicidality that those ones are still distressing, but not because it goes against their true kind of feelings or wishes. It's consistent likely with depression or mood pieces. So I've just seen this come up a lot, and even in my documentation, I'm having to talk about my decision making and noting the difference between this is it just seems to be an ego dystonic thought for this person.

Syma Khan:

I think that's so important. And we talked briefly about OCD and that aspect of it in another episode, and really again, calling to the fact that we need to be thoughtful about when there is a comorbid anxiety disorder that we're asking those right questions and we're providing space for youth to share their experiences openly. I think screeners are important because they really allowed us to target a large group, but then that follow up assessment is so important to really try and understand what that youth is experiencing, to then identify the correct and appropriate treatment intervention.

Christina Cwyner:

So we talked a little bit about the OCD and what we also know is that depression, bipolar disorder and personality disorders have that really strong association with suicidal behavior. But as we've been discussing, anxiety disorders are associated with the increased risk, especially in the transition from suicidal thoughts to suicide attempts. So the literature suggests that social anxiety in youth is in particular has been underdiagnosed, but also associated with risk factors for suicide. Can you comment on this relationship and maybe how early identification and intervention can be helpful?

Dr. Jamie Socha:

Yes. Social anxiety in particular has been noted for its overlap with some kind of key suicide factors like social isolation, loneliness, often just a slew of negative kind of self-perceptions. But at the core of this disorder is really a fear of embarrassing oneself, being judged harshly by others. But as you listen to socially anxious people kind of describe their experience. Another thing they talk about is a heightened awareness of other people's experiences. So I don't want to annoy them. I don't want to bore them. And so what can also develop is feeling like a burden to society, to other people. And that's often where I see this pathway to maybe depression or a suicidal ideation.

We do know there is a pretty high comorbidity rate between major depressive disorder and social anxiety disorder. So I think even in talking about or screening for social anxiety disorder, that mood piece especially is important to follow up with. I think you also mentioned early intervention and that piece. I think one of the main things this whole talk has got me thinking about today is that early intervention can really save lives. Because if we're helping people get the treatment they need, we don't see this trajectory into worsening anxiety and chronic anxiety too. So yeah, I think these things go really hand in hand, making sure people get the treatments that work as quickly as possible.

Christina Cwyner:

What you just said is really important. So that early identification and intervention, and I think some of the resistance I see is the stigma that we see in getting mental health care and getting it before maybe the rest of individual circle maybe sees a problem. Maybe the parent knows something's going on or the child's struggling with little aspects of things, but we don't want to make a big deal out of this. We don't want to pull the kid out of school to go to therapy or whatnot. I know schools have been doing increasingly more and more to help kids in place as well as just teach generalized coping skills and distress tolerance and everything, but that the stigma runs deep. I guess this is just my plug to say, the sooner we intervene and the more normal we make this, the healthier a child's going to be and the more they're going to thrive in their life.

Dr. Jamie Socha:

Yeah, I think if you talk to any clinician, seeing and treating a child where there's been this shorter window, perhaps when this has been identified and now they're in your office, it often doesn't take that long. I mean, cognitive behavioral therapy, the treatment that we're using for anxiety disorders is not a forever treatment. I think a lot of times the literature says 12 to 16 sessions, so if we can catch somebody early and really provide this treatment, it has a powerful impact on their life. It gets much trickier when somebody has been living with this disorder, those thoughts, those assumptions, those beliefs are becoming really entrenched. So that's a great point.

Dr. Christina Laitner:

And even for those more complicated cases, we also have evidence-based treatments also, right? This is not hopeless. This is where there's a huge evidence base at this point in time for DBT for adolescents, right? And there's a real overlap there. Again, for our anxious kids, really that skill of distress tolerance anxiety is a disorder of moving away. Distress tolerance is how do you tolerate distress? How do you sit with that? Wanted to also put in the plug that there's evidence-based interventions on all sides of things.

Dr. Jamie Socha:

That is a great point too. I see parents all the time saying, "I should have brought them in sooner. I should have brought them in sooner." I think, yeah, you probably hear that every day, but the truth is these treatments still work. Whenever you bring your child to therapy, they can make a difference.

Syma Khan:

And I think it again, brings us back to screening and the role that we play as healthcare providers to provide those opportunities because maybe that first time you ask that youth a question about their anxiety symptoms, it feels manageable. It feels like, oh, well, I have some of these thoughts, but they're not, it's okay. I think I can cope with them. But maybe in six months or a year when you ask them, they've kind of moved into more significant, and maybe now they're really starting to impair their function. And we've created that conversation, that space to hopefully be able to engage in support that youth to get that treatment and have that conversation with a family about what can they do as well.

Dr. Christina Laitner:

I think creating the connections and also the idea, I think we also want to, as we're working with these kids, that not only connecting to people, not only making safety plans, but this is also, there are a lot of choice points along the way. There's a lot of different points to intervene. And so I think that as part of this continued conversation that perhaps can help alleviate some of the feelings of hopelessness or entrapment, that there are people there that they can help them.

Syma Khan:

So we've spent a lot of time this season thinking about how anxiety can manifest differently for different individuals, but we also know anxiety is a normal emotion. What features of anxiety are particularly predictive or concerning for the development of suicidal ideation?

Dr. Jamie Socha:

Yeah, first I wanted to point out, you're absolutely right. Anxiety is a normal emotion. Normalizing the experience of anxiety is I think one of the most powerful things we can do initially for people. And it does something to instill hope, which a lot of people who are living with anxiety have kind of lost too. So a couple of things though come to mind when I think about maybe features or factors that might kind of increase the chance that somebody gets on this trajectory of experiencing suicidal ideation. One is just the chronicity of the disorder. I think that's what I was speaking to a little bit earlier. You can hear it in people when they're kind of describing, "I can never turn my brain off." "I can't go anywhere without feeling anxious." "Life is so much harder. Things take so much longer because of this anxiety." That really can lead to experience of helplessness and hopelessness for people too.

So that's a big thing I'm often looking at and seeing then maybe the development of mood disorders, secondary then to the anxiety. And this is probably me on my soapbox again, talking about evidence-based treatments, but I think it's not only getting people connected to treatments, but to the right treatment. So one scenario I see a lot are individuals who've lived with OCD, for example, for a very long time, and they're feeling very hopeless. And it's not uncommon that in their stories they'll say they've tried therapy here or there. One of the things we know about OCD is it requires a very specialized type of treatment. And I'm still kind of surprised the number of times people have never heard of exposure and response prevention, the frontline treatment for OCD. And so then they'll say things like, "I wish I knew about this sooner."

And so again, not only screening, knowing that those symptoms are there, but I think we can also educate our patients on what evidence-based treatments look like. What to ask for when you call to make sure that you're getting that right, that treatment. So chronicity I guess is a big one for me.

Dr. Christina Laitner:

And I think shame and guilt that the kids feel about their anxiety. We've touched on this about reaching out to others, shame and guilt can also then translate into that's a really uncomfortable feeling. I don't like that feeling. I'd like to stop feeling that way, and maybe I only know how to do that in a maladaptive way. That's another way where we sort of go off course.

Dr. Jamie Socha:

Yeah, absolutely. And that makes me think of, again, I'm thinking of what we kind of do to combat some of these things as well.

Dr. Christina Laitner:

Yeah, sure.

Dr. Jamie Socha:

And one of the things we do for that shame and guilt piece is we really try to help kids, heck, adults, externalize their anxiety. A lot of times that shame and guilt comes from feeling like one with their anxiety. They are their anxiety, they're broken. Why do they feel this way? So for kids, we'll externalize it for little kids. We'll even name it. We'll give their anxiety a name and that way they can start talking back to it. And I'll tell people, "We don't have to buy what anxiety is selling us, but we can really only start to think that way if we're thinking it as this different entity." And I find that when individuals start to do that, it does take away a little bit of that kind of shame and guilt. Anxiety is a part of them, but they are not their anxiety. So I think that's a pretty powerful thing that families, parents, really providers can do, even in just the way they frame anxiety for people.

Christina Cwyner:

I really like that reminder of externalizing the anxiety, and it's something I commonly do because I work with a lot of eating disorders so that we use that concept with those individuals struggling with that disorder. But I like it particularly because it takes the blame away from the person and it allows them to say, "Hey, Mom and Dad, Ted is causing me to have a stomach or a headache." Or, "It really made it hard to go to gym class today." Or whatever that may be, because it's not the child's fault. We are teaching that child how to manage some of these feelings and emotions and symptoms, whether they're physical or emotional or whatever they are in those contexts. So I really like that.

Not to jump to the next topic, but I want to keep us kind of on time here, but we talked earlier in this season a little bit about screening for anxiety, including the GAD-7, and you guys mentioned the SCARED earlier, but can you comment on the importance of screening not only for anxiety, but suicidal thoughts and behaviors and how to do this concerning this kind of screening and a variety of touch points across the healthcare system?

Dr. Christina Laitner:

I mean, I think it gets back to what you touched on earlier of this, just making sure we're embedding the suicidal and self-harm screening questions as part of our interview. Whether it's at a well visit, I can think back to when I worked on a consult liaison service at NYU and coming in and at a kid pre-op surgery right before we could go forward and something came up. This is a situation and where I will take false positives all the time. I will happily, that's what we're going for. We want to have the largest catchment in order to connect kids to care, right? Again, it's every time that they screen positive, it's an opportunity to make a safety plan. It's an opportunity to trusted adults, 988. It's all of those things. It's an opportunity for them to feel less isolated.

Syma Khan:

So thinking a little bit about treatment planning and sometimes the resources we may connect a patient or family to, especially when we're seeing youth that maybe have multiple needs, they're scoring high in some of that anxiety scales. They're also suffering from some depression symptoms, and they may be endorsing some passive suicidal thoughts. What would we want our healthcare providers or colleagues to think about when working with these youth?

Dr. Jamie Socha:

Yeah, I think providers in that role, again, getting that good screening, getting a little bit of the lay of the land, the overview. And then for those kiddos who look like they're reporting some of this, even if you're not sure, but again, that sub threshold group, connecting to a mental health provider and to really kind of dig in a little bit further and figure out what some of those treatment needs are. So one of the things we're doing when we're kind of meeting for our more comprehensive assessment after somebody might refer a child to us is figuring out what their treatment needs are, and perhaps even sequencing that.

These are not necessarily things I would expect a referring provider to know, but it's something that we're considering. For instance, anxiety is treated with exposure-based therapies. If we have a child with really low distress tolerance, that can be a really uphill battle. So sometimes we may sequence DBT or something where we work on that distress tolerance piece prior. But I think it goes back a little bit too to, of course, not only connecting to a mental health provider, but letting those families know there are evidence-based treatments for this and what those might be called too.

Dr. Christina Laitner:

I think another thing I'm so struck by when meeting with families is whether people's familiarity with the different levels of care that actually are available. I think sometimes we think it's either outpatient therapy 45 minutes a week or we're going straight to the emergency room. And that's really... So I encourage everyone to be familiar with what your local resources are. There's a lot of intermediate levels of care. Sometimes there's intensive outpatient programs where kids can come in multiple days, multiple hours a day while still attending school. We have partial hospitalization programs out there where kids can step away from school for a couple of weeks and do a therapy boot camp, if you will. So I think that's important.

And I also think for another scary thing or another barrier I think for parents is when we are starting to talk about the emergency room and what that process is, there's a chapter that I love, and I think I referenced it somewhere at the end called Kids in Crisis by Fadi Haddad, that really it's a parent-facing chapter and it walks them through what to expect when you bring your child into the emergency room. And I think that's an incredibly helpful resource. And also if you've never, as a provider, having walked in that space with a patient to understand what that's going to be like for them so that it can be as smooth as possible.

Syma Khan:

I think that's so important, especially as we talk about anxiety, because that's a little bit of what can be really helpful for an anxious youth with suicidal thoughts is helping them just be prepared of what to expect in that setting and letting them know it's not going to be scary. And so even for providers to maybe check out that chapter and we'll reference it on our webpage for people to be able to look over. So thanks so much for sharing that resource.

Christina Cwyner:

I was going to say it might be scary, but we will prepare them with the information they need to make it less stressful. And oftentimes, especially in our institution, like you're coming into an environment, whether that's our children's emergency room or a psychiatric emergency room where providers are trained to support the youth through that experience. But it is a different experience and it is something that is not the same as coming in for a medical concern. So that journey is very different. And I think we have an episode in season one that talks a little bit about this, but it will be an important thing to prepare your patients for if they are presenting to the ER for a higher level assessment.

Syma Khan:

I think that's helpful. And sometimes scary is good. We got to kind of put ourselves in those situations and hopefully get the support that we need.

Christina Cwyner:

I mean, it's what gets you on that roller coaster at the amusement park. Scary can be fun. Not that I want to equate going to the ER as fun, but sometimes anxiety and nerves have good endings.

Dr. Jamie Socha:

That's right. And treatment is never to make that feeling go away, to learn to manage it, and to learn that you can handle it.

Dr. Christina Laitner:

And quite frankly, with anxiety, I want the kids that I'm working with to have a little anxiety about suicidality. That is actually a protective factor. Having just enough of, I will leave you with the belief that death is scary. I will leave you that anything like that. That's fine. You can have that.

Dr. Jamie Socha:

Yes. That often is the irony, I noticed too.

Dr. Christina Laitner:

Yes. Isn't it?

Dr. Jamie Socha:

That protective factor is their anxiety about death dying.

Dr. Christina Laitner:

Yeah. Yeah. It's when it goes all the way to the other side that they get to come see you, Jamie. That's right.

Syma Khan:

So if you could leave us with one takeaway thought for listeners about anxiety, suicide, what would that be?

Dr. Jamie Socha:

I'm going to get on my soapbox once again and talk about just the evidence-based treatments and the importance of getting people connected to those and educated about those treatments. As Christina said, at any point we can intervene and make a difference, though the sooner the better. I also want to make a plug. I work with a lot of parents, not surprisingly, who are anxious and they really worry when their child won't engage in therapy. I work with a lot of parents exclusively in that case, when their child is anxious. So even if parents are feeling, my child won't go in for care, what can I do? We can work with parents and the family system and environment. So evidence-based treatments and knowing that they make a difference.

Dr. Christina Laitner:

One of my big takeaways I hope people take is talking about suicide and suicide risk does not increase the risk that your child when engage in those behaviors, it actually can alleviate the distress so they don't feel alone. And when a child does share those feelings, right, that's when we are making those safety plans with them, which includes differentiating between, is this an emergency room problem or can we cope with this, etc. And also really, I mean access to lethal means. And finally, one of the really things that I try to drive home to each kid that presents in my office with suicide risk is every moment is a choice, right? There's always another choice to be made. There's always another solution. Even if you can't feel it, that's why, or you can't see it. That's why you're working with a trusted adult. Because I think so often these kids sometimes see a permanent solution to a temporary problem. And that's the last thing that we want.

Syma Khan:

I know, there's hope.

Christina Cwyner:

There is hope, and I think we could really talk about this all day long, but I think we're definitely at our half an hour, if not past. So thank you both for being here today and sharing both your time and your expertise. We really appreciate you. Thank you to all our listeners for tuning in this week, and a special thank you to everyone that made the season possible, including Joe Hallissey and his team, Kat Bergman and her team, Rebecca Priest, and our colleagues that are currently covering us on service as we record. For the social workers, nurses, and physicians tuning in, you can claim CEs and CEUs at uofmhealth.org/breakingdownmentalhealth. We hope that you will join us next time.