Behind the Manuscript: Inpatient Treatment of Suicidality with Brett Jones, MD, MSc, PhD, FRCPC

Journal of Clinical Psychiatry: psychiatrist.com/jcp/

Inpatient Treatment of Suicidality: A Systematic Review of Clinical Trials: https://pubmed.ncbi.nlm.nih.gov/39832343/

Dr. Brett Jones: https://www.linkedin.com/in/brett-jones-1b308260/?originalSubdomain=ca

Center for Addiction and Mental Health:  https://www.camh.ca

University of Toronto Psychiatry: https://psychiatry.utoronto.ca

Ben Everett, PhD, is the creator and host of The JCP Podcast, a series that brings together leading voices in psychiatry to explore the latest research and its clinical implications. Everett earned his PhD in Biochemistry with an emphasis in Neuroscience from the University of Tennessee Health Science Center. Over a two-decade career spanning academia, publishing, and the pharmaceutical industry, he has helped launch more than a dozen new treatments across psychiatry, neurology, and cardiometabolic medicine. His current work focuses on translating complex scientific advances into accessible, evidence-based insights that inform clinical practice and foster meaningful dialogue among mental health professionals.

This transcript has been auto-generated and may contain errors. Please refer to the original recording for full accuracy.

00:00 – Honoring Dr. Nolan Williams

Ben Everett: Welcome to The JCP Podcast, where we explore the science and stories shaping mental health care today. I’m your host, Dr. Ben Everett, Senior Scientific Director with Physicians Postgraduate Press, publisher of The Journal of Clinical Psychiatry. On this podcast we speak with clinicians, researchers, and thought leaders advancing our field of psychiatry with a focus on not just what’s new, but what’s meaningful for our listeners in clinical practice. 

Today’s episode is in our “Behind the Manuscript” series and will also kick off a “Focus on Suicide” series.

Before I introduce our guest, Dr. Jones, I want to take a moment to acknowledge the recent passing of Dr. Nolan Williams. We’re recording this on October 20th, so about a week after it became public knowledge that that happened. This won’t air probably for another six weeks or so, but I want to take a minute and just acknowledge Dr. Williams and what he did for psychiatry. Dr. Williams was one of the bright young stars and most innovative minds in psychiatry, someone whose work reshaped how we think about treatment-resistant depression, neuromodulation, and the therapeutic potential of psychedelics. I had the privilege of working with him on a few projects and speaking with him about his vision for the future of psychiatry. His curiosity, energy, and generosity of spirit left a deep impression on so many in our field. We dedicate today’s conversation in part to honoring his legacy and advancing care for those struggling with severe and life-threatening psychiatric illnesses.

That said, my guest today is Dr. Brett Jones, a psychiatrist, scientist, and clinician-investigator at the Center for Addiction and Mental Health in Toronto, where he serves as Medical Head of the Bipolar Disorder Clinic and Assistant Professor in the Department of Psychiatry at the University of Toronto. A Fellow of the Royal College of Physicians and Surgeons of Canada, Dr. Jones completed his medical training at St. George’s University School of Medicine and both his residency and his doctorate in medical science at the University of Toronto, where his research integrated clinical neuroscience with molecular imaging to better understand the biology of mood disorders. He has received numerous awards for his work, including the CIHR Doctoral Graduate Award and recognition from both CAMH and the University of Toronto for excellence in research and fellowship achievement.

Dr. Jones’ research bridges clinical innovation with translational science, focusing on how novel and scalable interventions can improve outcomes for individuals with mood disorders and suicidality. His current work spans PET imaging studies exploring glial and synaptic dysfunction in bipolar disorder, as well as digital and mechanistic trials targeting acute suicidality in the inpatient setting. Through this line of work, he aims to translate neuroscience discoveries into practical treatment strategies that could be implemented in real-world clinical care, work that aligns directly with the topic of today’s discussion on inpatient treatment of suicidality, the title of his paper that was published in JCP earlier this year. We’ll have a link to the paper in the show notes. 

So with that, Dr. Jones, welcome to The JCP Podcast.

Dr. Brett Jones: Thanks very much for having me. It’s an honor.

03:07 – Career Path into Psychiatry and Suicide Research

Ben Everett: We’re excited to have you. I think this is a very important topic and a topic where there’s been a lot of research, but it’s difficult sometimes to synthesize these different researches. So I really like the approach that you and your collaborators took in this paper.

 Before we get into that, we start every episode with sort of an icebreaker to get to know you a little bit as a person and figure out what makes you tick and what made you think about science and medicine. You have dual doctorates. We’ve actually had four guests in a row that are dual-doctorally trained. One was enough for me. You completed your medical training first, then you did your PhD while you were doing your fellowship. Did you know from a young age you were going to go into medicine? Or was it science first, or kind of tell us about your journey.

Dr. Brett Jones: Yeah, one wasn’t enough. I had to do two. So I’ve had an interesting journey. I’ve always been interested in science. I’ve also been interested in culture and societies. I did an undergrad with a political science minor. So I really kind of was exploring a lot of different things. Later in undergrad I became quite interested in behavioral neurology. Then I decided to pursue a master’s after undergrad. That’s where I really got interested in research. But it’s also where I really reaffirmed the idea of doing medicine. I really saw that as the frontier of where we could integrate research into real-world outcomes. And so I went to medical school and then it was during residency that I had an opportunity to explore some neuroscience-related research. I decided to package that up in a PhD. There was a really good opportunity, so I jumped on that and that’s how I ended up doing the fellowship and the PhD training.

Ben Everett: A lot of neuroscience and clinical science. Did you know when you went to medical school, were you thinking psychiatry, neurology, or were you open-minded?

Dr. Brett Jones: I definitely went in there telling people I wanted to do psychiatry. The master’s that I did was in psychiatric research and so that was the field of medicine I really wanted to explore. That being said, I was very open to learning all aspects of medicine. I didn’t want to shut any doors, but I would say that I was very much psychiatry from the start.

Ben Everett: And then in your fellowship you did mood disorders and psychedelics. Tell us a little bit about that. I’m personally very interested in psychedelics.

Dr. Brett Jones: Psychedelics are something that I’ve actually always been very interested in, even from early days. I was very interested in them from a cultural perspective and just how they sort of integrated into societies and influenced people’s thoughts and interpretations of the world and the meaning of life and all these sorts of things. It’s something that’s really fascinated me. When I was a resident, it really started to reemerge in the more scientific popular culture and people were actually researching it again. There was an opportunity to collaborate with my main mentor, Dr. Husain, who’s leading a clinical trial of psychedelics at our center. Starting to work with him, I really wanted to explore how this very fascinating, rapid-acting treatment works. With my interests in neurobiology and understanding mechanisms, exploring psychedelics was a neat way to both effectively treat people and really understand the biology of what was happening. When you have such a rapid antidepressant response, you really don’t need as large a sample size all the time to dive in and try to answer some of the questions around mechanisms, because the effects are so large. You can really start to see what’s happening. That shaped my interest in looking at the psychedelic science and understanding what’s happening in the brain with these treatments.

Ben Everett: If you didn’t go into medicine and science, could you see yourself doing anything different?

Dr. Brett Jones: When I graduated high school, my band and I moved to Toronto together. We all kind of had one foot in the door for academia and were also trying to really make our band work and make it big. Music is always something I’ve loved. If I could do that, I think that would be a lot of fun. I wanted to be a pilot for a while. I think that was something I considered quite a bit. But you know, I think research and medicine really are a big passion of mine.

Ben Everett: All that rings true to me. I grew up playing the drums and I’ve been wanting to pick up guitar forever. I finally bought a guitar about a month ago. So now I’m just trying to figure that out, which is… I thought neuroscience was hard, you know?

Dr. Brett Jones: Yeah, I play bass guitar, but I always wanted to play drums, too.

Ben Everett: You gotta do the rhythm section thing, right.

To help frame our conversation today, could you tell us about the rationale for this paper on the inpatient treatment of suicidality and research efforts on suicidality in psychiatric inpatients?

07:59 – Why Inpatient Suicide Treatment Needs Better Evidence

Dr. Brett Jones: I think suicide is obviously the most severe, worst outcome within psychiatric conditions. Across all psychiatric conditions, there can be some degree of suicidality. On a personal level, about a month before starting residency, my best friend died by suicide. Starting the residency training, having to work in inpatient settings and emergency rooms working with people with high levels of suicide and trying to treat this, it took on a really important meaning to me. I was exploring different research opportunities and different clinical opportunities trying to explore this interest of mine. When the pandemic hit- when I was researching, I realized there was a big gap around what was actually available to specifically treat suicidality. I saw that there was some evidence that if you treat it directly, the outcomes can be better. Then when the pandemic hit, that gap just even worsened for our center. Essentially, there were almost no psychotherapeutic interventions anymore. Everything had to be closed off. People had to stay in their rooms on the inpatient unit. I really saw that as an opportunity to look into the literature more, just to see what options are available, because the gap really became much more transparent.

Ben Everett: Thanks for sharing. Certainly, sorry for your loss. As prevalent as suicide is now, you find so many people that have a personal connection to it. 

Just to kind of help set this up, I’ve got a little blurb I’ll read. We know that suicide is one of the most urgent psychiatric emergencies clinicians face. Patients admitted to the hospital for suicidal thoughts or behaviors represent an especially vulnerable population. They’re often experiencing intense distress. They have limited coping capacity and elevated risk during and immediately after discharge. Hospitalization obviously provides safety and stabilization, not during the pandemic, I guess, in the traditional sense, but it also represents a critical opportunity where we can maybe deliver interventions that directly target suicidal thinking as opposed to just focusing, “Okay, well, you’re depressed because you’re cycling with your bipolar disorder,” or whatever else. Yet, despite decades of research, we really still have limited evidence about which treatments are most effective for reducing suicidality in the inpatient setting. That is really the focus of our conversation today. Why did you and your team feel like a systematic review focused specifically on this was needed?

Dr. Brett Jones: You summed it up really well. I think there are a lot of studies out there. I was reading and seeing the evidence, but the consensus as to what would be the most effective treatment and for whom really wasn’t there. We were designing a pilot randomized controlled trial for a digital intervention. This was sort of what the pandemic had motivated us to do. We weren’t allowed to have as much close contact at the beginning of the pandemic, so we thought that a digital intervention would be a neat and novel way of breaking that challenge. When we were developing that study and thinking about this problem, we thought, given that there wasn’t a clear consensus at least within the literature that we were reviewing, that a review would be a helpful way to summarize what’s been done and what may be an effective next step.

Ben Everett: Well, I really enjoyed the paper. I think it’s an exhaustive review of the literature. Can you walk us through your review? What was the design, what databases did you use, and how did you think through inclusion and exclusion criteria?

Dr. Brett Jones: We worked with a librarian at the University of Toronto. We reviewed many different databases, some that are more biologically oriented and some that are more psychologically oriented. We also reviewed a nursing database specifically, because a lot of interventions, particularly on inpatient units, may be nurse-led interventions. We wanted it to have broad inclusion criteria. We didn’t focus on one specific psychiatric condition or one specific population, given that suicidality can come across all psychiatric conditions. We focused on biological and psychological-oriented interventions. The key, though, that we really wanted to focus on was that a measure of suicidal ideation or behaviors had to be either the main outcome or a secondary outcome of the intervention. The intervention also had to be done in the hospital. That really was the main formatting of the paper.

Ben Everett: I know you focused exclusively on adult patients 18 to 65, just to throw that in to make sure our listeners follow appropriately. You focused specifically on clinical trials that have been published, rather than just broader prevention strategies. It seems to make sense that you would look for peer-reviewed, published evidence of actual treatment success, looking at reduction in suicidality as a primary or key secondary endpoint. What did you find in terms of limitations of the studies?

12:59 – Key Limitations in Suicide Intervention Research

Dr. Brett Jones: A second piece I just want to mention about the rationale for the clinical trials is a lot of the interventions currently are things like changing the environment, sort of reducing the ability to do suicidal behaviors. What we really wanted to focus on was actually treating specifically the suicide, which I think was an important methodological piece. Regarding the limitations, we actually were able to find quite a large amount of papers from the review, more than I had suspected from the outright. This is both a positive and a limitation. There’s a wide diversity of interventions that have been studied, which is actually reassuring. But the amount of reproduced interventions or the amount of interventions that have actually been studied in multiple centers or by multiple teams is not as high, which can be a challenge when it relates to translational opportunities. Many of the studies were small, and many of them were unblinded, which reduces the overall strength of the evidence. It’s still important evidence, nonetheless.

Ben Everett: With the help of the librarian, you all found almost 20,000 total articles. There were about 8,500 duplicates. So that still leaves like 11,519 that have to be screened. You screened the abstracts and then found 179 for full-text review. Of those, you had 14 that just looked at pharmacological interventions and 35 that covered nonpharmacological trials.

We’ll get into the results. Let’s start with the pharmacologic interventions. Not surprisingly, I’d say, due to how rapidly it acts, and you indicated this in the introductory comments, ketamine really dominated much of the inpatient literature on the pharmacologic side. What stood out to you about its effects on suicidality in terms of timing of response, durability, and those types of things?

14:57 – Ketamine and Rapid Acting Treatments for Suicidality

Dr. Brett Jones: Not surprisingly, ketamine was the main pharmacological treatment that was investigated. There were a few studies that looked at it very specifically around suicidality in inpatients. Some of them were also secondary analyses of larger studies just looking at that clinical question. For both the different formulations, the IV formulation or the intranasal formulation, both had some degree of positive outcomes with respect to suicidality. Some of the reduction in suicidality occurred even within hours, which can be very promising for somebody who is experiencing very severe and significant distress. The studies were a little bit heterogeneous, largely looking at mood disorder-related suicidality. Some of the questions though may be: How long does this reduction in suicidality last? What interventions need to occur next? These are important things to consider from these studies.

Ben Everett: In terms of the IV and intranasal, people can get compounded racemic intranasal, so not necessarily just the esketamine product. I’ve also seen the orals compounded into lozenges and gummies and things like that. Did any one of these formulations stand out above the others in terms of treatment effect?

Dr. Brett Jones: The evidence for IV ketamine appeared to be a bit more consistent, though not 100 percent. For the intranasal studies, there was a positive study, but there were two larger studies that showed significant reduction but not different than placebo. These are versions that do work with respect to major depressive disorder. There is evidence suggestive of that for treating depressive episodes. I think it really highlights the importance of looking at suicidality. Either some treatments are effective at improving depression but maybe not necessarily at improving suicidality, or treatments that are effective for people with major depressive disorder who are outpatients may not translate to potentially a more severe spectrum of the condition for those that are admitted with severe forms of suicidality. So it just really highlights the importance of looking at this population and looking at suicidality specifically.

Ben Everett: Esketamine trials, as you mentioned, were mixed. What do you think accounts for this discrepancy? There was a lot of early promise for esketamine, especially in this setting. Obviously, it is a little bit easier to do an intranasal formulation than IV. Is there anything that you think accounts for that in your review of the literature, such as study design, limitations, or is it just kind of what it is? You mentioned the placebo effect was really high also.

Dr. Brett Jones: One area of interest that I have is in placebo effects. I think that’s a very fascinating, understudied area and trying to understand the mechanisms of that. Clinically, to give context, I work in the emergency room, so I see people when they present with psychiatric emergencies. I also from time to time work in the inpatient setting. There can often be this heightened level of distress and severity of symptoms when somebody presents. Sometimes they’re not sure whether or not they’re going to get the care that they hope they’re going to get, or there may be other factors as well, like substances or other psychological stressors. When somebody comes up to the inpatient unit, there can almost be a little bit of a calming effect. They feel like they’re in the right place and their care needs are going to be met. Speaking generally, this can happen, though it’s not always the case. I think it’s very challenging to try to isolate the effect of medication when there are also other treatments happening at the exact same time. The therapeutic milieu, engaging with the nurses, and speaking with your care team are all treatments. They’re all working to reduce suicidality. So there’s a pretty strong comparator. It’s not just a placebo necessarily. There is this additional factor as well. I think it can be hard to isolate these effects.

Ben Everett: I think it’s certainly true with placebo. People seem to think sometimes it is worse in mental health, but we see it in all areas of medicine. I’ve done research in a number of different therapeutic areas, but I think there is something about these mental illnesses and serious mental illness that are especially prone to these things. You get patients in a study, and they’re meeting with clinical coordinators and clinical nurses on a regular basis. If it’s inpatient, you’ve just got a lot of patient support that goes into that, and that certainly plays into this placebo effect. So it is difficult to tease it all out for sure.

For pharmacologic interventions, it wasn’t just ketamine. You also found some studies looking at buprenorphine as well as duloxetine. What did you find there?

19:48 – Emerging Treatments Beyond Traditional Depression Care

Dr. Brett Jones: Those are actually quite interesting. I wasn’t expecting that, but I think there was a single study for each. What I find most fascinating about that, obviously with buprenorphine there would be pause for concern regarding addiction potential, and you’re creating additional problems with dependency. But what I found most fascinating are the potential mechanisms that could be hypothesized from that, and how maybe suicidal thoughts and suicidal behaviors may relate to opioid-related mechanisms and receptors and trying to understand how that could have been helpful. The same is true with duloxetine, given that from that study the antisuicidal effects were independent of depression-related effects. What’s happening potentially related to norepinephrine might influence cognitive control, which we do know is closely linked to suicidal thoughts and behaviors. From those studies, I think there are quite fascinating potential mechanisms to explore with either those treatments or related treatments.

Ben Everett: This is definitely hypothesis-generating research that you’ve pulled together here. There are a lot of different areas that other people can look at now and say, “Okay, there’s a lot that we can hypothesize and think about in terms of treatment, sequencing, and additive effects of maybe different things.” Some things are rapid, some take a little bit longer to work but have more durability, and there are all sorts of things that come to mind. Of course, the way clinical science works, it’s always baby steps and kind of one thing at a time. 

Let’s move into the nonpharmacologic interventions. There were 35 trials that were included looking at things like chronotherapy, neurostimulation, CBT or DBT, trauma-focused approaches, especially since PTSD has a very high rate of suicidality, and then comprehensive care models. It’s really a mixed bag there. Of everything that you found, what do you think appears the most promising for inpatient settings today?

Dr. Brett Jones: We did lump the brain stimulation within the nonpharmacological category. Arguably, we could have had that as a separate subcategory. I think for inpatients particularly, one thing that really stands out and why it was important to do this type of work to outline what’s feasible and what’s been helpful, is that you have a very captive audience. The people are there, and they’re available throughout the day to provide interventions to. One of the biggest barriers to receiving treatments like rTMS or ECT, or evidence-based psychotherapies, can be geographical, like having to come to the clinic to do the intervention. There’s a real opportunity for some of these treatments to be delivered, such as rTMS that requires daily stimulation, or ECT that requires specialized collaboration with anesthesiology and post-anesthesia care. Those interventions certainly stood out. Then some of the manualized-based psychotherapies, such as CAMS or integrating CBT and DBT, I think are really good opportunities to work with people while they’re there and really provide the care to the people when they need it and when they are most likely to benefit from that.

Ben Everett: Of all these different things, did anything stand out as being maybe more promising for inpatient settings today, or was it still kind of a mixed bag?

Dr. Brett Jones: I think some of these interventions certainly could be quite promising. It’s nice to know that some of these rTMS protocols and ECT actually have direct suicide-related effects potentially. That’s quite promising because they can be a bit more resource-intensive. Having the evidence to suggest that they may be helpful may be beneficial when planning how to run inpatient units. Some of the chronotherapy was something I actually didn’t know about, and it came about while doing the research. That certainly can be quite a low-cost intervention. So that’s quite fascinating and promising if it turns out to be effective. There are a few manualized psychotherapies specific for suicide. Seeing that those are feasible and effective is actually quite promising as well because they’re designed to treat specifically what we’re targeting here.

Ben Everett: The one that really stood out to me, again, I’m just kind of a biochemist and neuroscientist by background and I haven’t really looked into suicide and suicidality that much, was the sleep deprivation actually having some impact. I kind of went back to the literature just to look that one up. There’s at least one study that was published in JCP back in 2013, so it’s not exactly that new, but it actually had some good effects. I thought that was really interesting.

Dr. Brett Jones: I shared the same feeling when I saw that. There is some legitimate biology behind that. Sleep in and of itself is also, if we’re talking about unifying symptoms across psychiatric disorders, a major factor. Sleep disturbance is a symptom in almost all psychiatric conditions. So it makes sense that targeting sleep or rhythms would be a potentially effective treatment for sure

Ben Everett: It’s a very dramatic amplifier on top of already a serious mental illness.

To move to the next phase, that really covers most of the findings of the study. Let’s talk about implementation and real-world application. How can inpatient units translate these findings into practice, given the differences in staffing, resources, and acuity? As you indicated earlier, if you’re at an academic research institution, you tend to have more of the psychotherapeutic services available. You might have larger psychology, social work, and therapy staffing that can help address these things that you might not have at other places.

25:47 – Translating Research into Real World Inpatient Practice

Dr. Brett Jones: I think it’s really important to think about how this type of research can translate into actually treating and helping patients. Psychiatric inpatient units are incredibly diverse and heterogeneous in the approach of how they operate. I can speak to our center. It’s very much an acute care. People are usually on our units for a couple of weeks, not much longer typically. So we have a very small window where we can intervene. If we were to look at how we could translate this research into the clinical setting we work in, we would obviously want to focus on interventions that could be delivered in a shorter period of time or ones that can continue into outpatient care. But if there’s an inpatient setting that’s more rehabilitative or has a longer time where people are typically admitted, then looking at how some of the interventions are a bit longer may be helpful. I think it’s also really neat to see which interventions have a more rapid response, because these are ones where, if there’s very significant clinical distress, they can be implemented quickly. Sometimes if somebody is extremely distressed and very focused on suicidal thoughts, it can be very hard to target other aspects of their treatment as well. It could be sort of like a treatment algorithmic, stepped approach as well.

Ben Everett: I think that’s really important context to think through for all this stuff. 

In terms of barriers, what do you see regarding implementing rapid-acting or structured psychotherapeutic interventions during the short hospital stays? In the United States, we have a very different healthcare model. Sometimes even two weeks is going to be considered really long. A lot of times it’s just, “Let’s get them stabilized and try and get them discharged.”

Dr. Brett Jones: It’s an important point you make. Every area has a different standard and what is typical. When we think about barriers, one of the biggest barriers would really be what is feasibly practical. If there isn’t an ECT machine or rTMS machine at your hospital, that might not be the best way to go. IV ketamine requires continuous monitoring for the period of time while administering it. If that’s not possible at the center, then there are a lot of steps that have to occur beforehand. Really trying to see the inpatient stay as a part of the overall arc and trajectory of the patient’s treatment and not just a single isolated moment is where the barriers can really be addressed. So getting the intervention started during this critical window, but also being aware this inpatient stay may end in three to five days. How can this intervention continue as an outpatient? 

The time after discharge is an area we could have written a paper just on: treatments of suicidal thoughts after discharge from the hospital, because that is an equally pressing and high-risk clinical time. Really having good integration between inpatient and outpatient services so that any intervention that is done, however short or rapid, any benefit can continue. I think that’s probably a big barrier to overcome as well.

Ben Everett: Is there anything that you think is just ready to pilot more broadly right now based on this? There are a lot of implementation things that we’ve just talked through. Anything that you think is ready for a larger study or a full-on pilot study?

Dr. Brett Jones: I think large studies with some of the IV ketamine or some of the brain stimulations. One area that wasn’t in this review because the papers hadn’t come out yet is psychedelics, since we had spoken about that earlier. There is some interesting evidence of psychedelics in reducing suicidality. The inpatient unit is a safe, contained environment which I think would be particularly beneficial when treating a suicidal patient with psychedelics. That is a bit of an aside, but I think it has potential. 

I think the most practical and feasible next steps would be some of these manualized psychotherapies that are really targeted towards suicidality. If you think about the hierarchy of evidence with open-label trials, RCTs, and multicenter RCTs, having a manualized treatment for psychological interventions would be the easiest to study across centers and across inpatient units. Something like the CAMS psychotherapy, which has some pretty good evidence for both outpatients and inpatients.

Ben Everett: Looking into future directions, where do you think are the key gaps to be addressed in this topic?

30:38 – Major Research Gaps and Need for Better Clinical Trials

Dr. Brett Jones: I think what this paper did well to outline was that there’s a large number of studies that have looked at this clinical question. Despite the amount of studies, at least in the world that I practice in and my academic area in Toronto, there isn’t a clear treatment guideline or algorithmic approach on how to address suicidality of an inpatient. It really is treating the underlying disorder, containing risk, and really hoping that the suicidality improves with that. To get to a point where we can really have approaches to treating people with complex presentations and significant suicidality, having large randomized controlled trials evaluating very specifically this question. For example, some of the evidence was retrospective analyses of clinical studies. Common practice among clinical trials is to exclude people with high levels of suicidality. A number of these studies may actually have not included even the highest spectrum of the severity. It’s actually the more moderate level of suicidality. Designing studies that are specifically built to evaluate the effectiveness of treating suicidality, not as a primary outcome retrospectively or a secondary outcome, is very important. 

I think there can be a lot of opportunity in figuring out how we can potentially integrate different modalities of treatment, different sequential treatments. Thinking about this, if somebody is admitted to the hospital and has very severe suicidality, they’re treated with IV ketamine, and the suicidality rapidly decreases. Is this now the time when an intervention like CAMS should be implemented? Is that more effective than doing CAMS alone, or doing them together at the same time? Trying to figure out the best approach for whom, how, and when we can implement different treatments would be a really unique opportunity.

Ben Everett: We’re getting ready to wrap it up. I’ve got two more questions for you. Just based on your study and everything we’ve talked through today, if you could leave our listeners with one key takeaway from the review, what would it be?

33:04 – Hospitalization as a Critical Window to Prevent Suicide

Dr. Brett Jones: I’d say one key takeaway from this review is that hospitalization is a critical window of opportunity. It’s when people with psychiatric conditions are presenting, and sometimes it’s the most severe that they’ve ever presented. It can be one of the hardest and most difficult times in their life. It’s a very key moment to really change the trajectory and really help people. Making sure that we are working with the best level of evidence and the best level of care is critically important. There is exceptional evidence, which this review was able to show. The next step is to really try to understand how we can implement these treatments and for whom they may be the best.

Ben Everett: I think that would be great to figure that out. 

So finally, what are you working on now? Are you looking to move into a larger clinical trial based on this, or is it more just your pet stuff looking at brain imaging and psychiatric function? What are you working on now?

Dr. Brett Jones: I’m working on a lot of things. I’ve recently transitioned into this medical head role treating bipolar disorder at CAMH. A lot of what I’m trying to do is, while developing this clinical program, integrate real-world research into it, which would include observational studies and randomized controlled studies with respect to this suicidal topic of inpatients. 

We recently published, maybe a few months ago, the pilot study that looked at digital DBT for treating suicidality in psychiatric inpatients. There was a small study, about 20 people per treatment arm, and we showed a good effect with a digital version of DBT. That was published in The Canadian Journal of Psychiatry. We’re going to look at trying to replicate that in a multicenter study across Toronto to see if we can replicate these effects. I think it’s also a really neat opportunity. We did that intervention before the big AI boom. It’s a neat opportunity to try and refine the digital intervention. What does a digital intervention actually look like in 2025 or 2026? Because the one we worked with was from 2019. That’s an area of interest. 

The last area is within the world of psychedelics and mechanisms. We’re conducting some clinical trials of psychedelics within mood disorders and looking at mechanisms of change, whether that be PET imaging or peripheral biomarkers. We’re still trying to understand how these treatments work and also understand what’s contributing to mood disorders and how best we can develop future treatments.

Ben Everett: Well, we look forward to it. Sounds like you’ve got a lot going on.

Dr. Brett Jones: Thank you.

Ben Everett: I think I would be remiss if I did not mention, I don’t know if you’re a baseball guy, but the Blue Jays forced a game seven last night in the ALCS. I thought for sure after two nights ago Seattle was just going to take you out last night.

Dr. Brett Jones: I thought so too. If this is being released in six weeks, we’ll have a 2025 World Series Champions Blue Jays, hopefully.

Ben Everett: Yeah, there you go. Well, if that happens we’ll have you back on just to celebrate.

Dr. Brett Jones: Exactly. I’m excited to watch the game tonight.

Ben Everett: I was just happy the Cubs are playing good again. I’m a Mississippi guy. We don’t have any professional teams. A lot of people did the Braves, but WGN would just broadcast everywhere, so we could get it with our rabbit-ear antenna growing up. I grew up listening to day games and Harry Caray. I’ve kind of been a Cubs fan forever, but at least they were finally better again this year.

Dr. Brett Jones: I quite like the Cubs. I have been to Wrigley Field and it’s nice.

Ben Everett: I love Wrigley.

Dr. Brett Jones: Nice atmosphere.

Ben Everett: Yeah, it’s just one of the classics and they love it. They’re not going to build some mega-stadium like everybody else seems to do. It’s just one of those classic ones. I think Fenway is the same way. It’s just classic baseball, Americana baseball. 

All right, Dr. Jones, thank you so much for coming on the podcast today, sharing your research, and going through this paper with us. I think it’s really important, and I invite everybody to go check it out. I really enjoyed reading it, and this conversation today has been great. I’d love to have you back on in the future.

Dr. Brett Jones: I’d be honored to. This was a lot of fun. Thank you.

37:29 – Up Next: Dr. Marc Agronin

Ben Everett: I do want to set up our teaser for next episode. I hope everybody joins us. I’m going to sit down with Dr. Mark Agronin from Miami Jewish Health. He’s a nationally recognized geriatric psychiatrist and author whose work bridges neuroscience, compassion and innovation in aging. He’s doing a lot of work in Alzheimer’s disease. I saw a talk he gave at Psych Congress in San Diego a few weeks ago and I knew there was like new work going on in Alzheimer’s disease, I had no idea the volume of work that was going on in Alzheimer’s disease. And he is engaged with all of it. So we’re going to sit down with Dr. Agronin. He’s going to get us up to speed with what’s going on with Alzheimer’s disease research. So I hope you join in for that. You’re not going to want to miss it.

With that, I’ll say this has been The JCP Podcast: Insightful, Evidence-Based, Human-Centered. Thanks for joining us. Until next time, stay curious, stay informed, and take care.