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Dr. Igor Galynker: An AFSP Research Spotlight Interview

28 Sep 2021 — 6 min read

By AFSP

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Igor Galynker, M.D., Ph.D.

Depression Hell: White-Knuckling Mental Illness After a Suicide Attempt

Igor Galynker, M.D., Ph.D., is the Director for Research in the Department of Psychiatry at Mount Sinai Beth Israel, and the founder and director of the Galynker Center for Bipolar Disorder. He is a clinical professor of psychiatry at the Icahn School of Medicine in New York City. Dr. Galynker is the recipient of three research grants from AFSP that have been fundamental to his work, including a Standard Research Grant in 2009, a Focus grant in 2015, and a Linked Research grant in 2019.

As a researcher, what first interested you in studying suicide?

I changed the focus of my research from bipolar disorder to suicide prevention in 2008. I had both conscious and unconscious reasons for this change. The conscious reason was that I had attended a grand rounds talk given at Beth Israel Medical Center by Dr. Paula Clayton, who was then the American Foundation for Suicide Prevention’s chief medical officer. The talk was all about the brain chemical serotonin but didn’t include anything about what may happen in somebody’s mind in the minutes and hours preceding suicide. I asked Paula what was known about the acute suicidal mental state, i.e. what was different in the mind of a person about to kill themselves, as opposed to what was in their mind the day before. She said she did not know. Moreover, she said there was no framework for the syndrome of acute suicidal mental state. At that point, I realized that I had stumbled upon a hidden gap in our knowledge of the human mind that psychiatrists were not aware of, and that must be urgently filled. This was the moment that changed my professional life.

The unconscious reason for my interest in changing the focus of my studies had to do with the suicide death in 1993 of one of my first psychotherapy patients. I was then a first year attending at Beth Israel, fresh out of residency. Bernie (not real name) was a 55-year-old gay man who had suffered a catastrophic loss. His long-term partner had died suddenly, and at the funeral he learned that during their 30 years together, the partner had led a double life: he had also been married to a woman, and they had three children. When I saw Bernie for the first time, he wanted to die by suicide, and (unbeknownst to me) had a plan for doing so. However, he was willing to give me a chance to try to help him. We struggled together for a year. Unfortunately, he did then take his own life – but not before sending me a gift with a thank you note, including an apology for hiding his true intent. It took me years to heal from his death. 

Could you explain your theory of Suicide Crisis Syndrome (SCS), initially known as Suicide Trigger State?

Suicide is the only mental health condition with a predetermined lethal outcome. Suicide is THE main cause of death in all the major psychiatric disorders: schizophrenia, bipolar disorder, major depressive disorder, and borderline personality disorder, all with more or less the same rates. It was inconceivable to me that such a condition would not have a distinct phenomenology (emotional experience) and brain biology, and be included in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) where all mental health conditions are described.

After my experience with Bernie hiding his suicidal intent, I also realized that our reliance on suicidal ideation to identify those at risk has been misguided. Would you ever rely on a person with schizophrenia to diagnose their schizophrenia, or a patient with bipolar disorder to diagnose their own bipolar disorder, or a patient with diabetes or heart disease to diagnose themselves? Probably not – yet we paradoxically rely on patients in an acute suicidal crisis, which is a potentially imminently fatal condition, to diagnose their own suicide risk. 

My team’s hypothesis was that a syndrome does exist – a “Suicide Trigger State” or “Suicide Crisis Syndrome” (SCS) – that could be described through its association with imminent suicidal behavior.

Our long-term plan had two phases. In the first, we planned to describe the phenomena associated with the SCS. In the second, we intended to identify possible underlying neurobiological mechanisms that could guide targeted medication treatments. At the outset, we decided to exclude suicidal ideation (SI) from the syndrome; not because it wasn’t present, but because the self-report of SI was often unreliable and even misleading.

The initial phenomenology, that is philosophy of the experience, of SCS was based on my clinical experience. I observed what we initially called the Suicide Trigger State in many patients who went on to make serious suicide attempts, and in several that went on to die by suicide. The STS appeared to resemble uncontrollable panic. The main symptoms persisting from case to case were frantic anxiety, the inability to shift from unhealthy thinking, feeling cornered, and agitation.

Having formulated the syndrome, we created and validated a scale to measure it, and worked to determine if it was predictive of imminent suicide attempts. Over the next several years, we proceeded to refine our scales, and each subsequent scale got better at predicting suicidal behavior than the traditional risk factors for near-term suicidal behavior.

How have you gone about testing your theory?

We have run a series of studies describing the SCS and showing that it is a real syndrome that can be measured to identify someone at immediate risk for suicidal behavior. During the COVID pandemic, we assessed the presence of SCS in 14 countries on four continents 

The Modular Assessment of Risk for Imminent Suicide version 2.0 (MARIS-2), our current measure, is unique and innovative in that it has two informants, the patient and the clinician. MARIS-2 combines the assessment of SCS severity with that of clinicians’ emotional response to suicidal patients, as measured by the Therapist Response Questionnaire Suicide Form. Our MARIS studies have demonstrated that clinicians’ emotional experiences of a patient are related to the patient’s risk for suicide.

This latter finding is unprecedented and adds a new dimension to suicide risk assessment involving the use of clinicians’ emotions to assess suicide risk. However, clinicians must be both exquisitely self-aware and have the skills necessary to manage this self-awareness. These skills are necessary in order to maintain empathy and an understanding of their patient’s feelings. 

How has AFSP played a role in your research?

From my very first meeting with Dr. Clayton, AFSP changed my career path and supported my research. Our first grant funded the creation and validation of the Suicide Trigger Scale and the description of the Suicide Trigger State. Our second AFSP grant, the Focus Grant, supported a large scale study demonstrating that MARIS works to assess immediate risk and resulted in over 30 publications. This work also led to the discovery of another pre-suicidal state we have named the Suicidal Narrative and the formulation of the Narrative-Crisis Model of Suicide (NCM). The Narrative is the person’s perceived life story that has no acceptable future and thus may result in their suicidal crisis.

Our current grant supports the development of virtual human emotional intelligence, a virtual patient, to train clinicians to be aware of and accept their emotions, while responding to suicidal patients with empathy. This grant helped us to secure an award from the National Institute of Mental Health (NIMH) to study the virtual Human intelligence training program and see if it can help improve clinicians’ confidence, reduce their stress level and improve patients’ suicidal outcomes.

Finally, I am now in a position to encourage and mentor early career researchers to enter the field of suicide prevention research. Over the last two years, two members of our research group were awarded Young Investigator grants by AFSP to expand the work to help adolescents in culturally diverse setting. 

Have you noticed an impact from your work?

I’ve noticed impact because clinicians are using our instruments and training programs. The scales can be downloaded from the lab website https://labs.icahn.mssm.edu/galynkerlab/

One of most impactful consequences to date may be that in 2020, the Northshore Healthcare System in Chicago began using our patient assessment measure (SCI-SF) and found it to be a tool of choice in making decisions about patient care such as whether or not to hospitalize a person for suicide risk. 

Another new and important finding was the discovery that clinicians’ emotions toward their suicidal patients can help predict risk for imminent suicidal behavior. We developed a virtual patient and a training program that can actually improve clinicians’ emotional self-awareness and ability to engage in empathic communication with their patients: an important ingredient for reducing imminent suicide risk.

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