U.S. Suicide Rates at All-Time High: American Psychiatric Association President Responds

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Mark Masselli ( 00:04 ):
Our guest says more and more people are publicly discussing their struggles with mental illness and
substance use disorder in an open and honest way, that would've been hard to imagine a few years ago.
He and his colleagues see this is a great opportunity for psychiatry to make a difference.
Dr. Petros Levounis ( 00:22 ):
We used to scream from the rooftops about, "Wake up, mental illness is such an important issue." And
people were like... We would land on deaf ears. And all of a sudden the tables completely changed and
people are screaming, "We need more help, we need support, we need services, we need this and this,"
that we haven't been prepared to respond to this kind of demand. So this where our work cut out for us.
Speaker 3 ( 00:47 ):
For the longest time, it was hard for me to even get out of the house, much less do a backside 180. It
took me a bit to understand what was going on, but eventually I learned I had anxiety.
Margaret Flinter ( 01:01 ):
Joining us is Dr. Petros Levounis. He's the President of the American Psychiatric Association, which
represents over 38,000 physician members who specialize in the diagnosis, treatment, prevention, and
research of mental illnesses.
Dr. Petros Levounis ( 01:15 ):
We do know that medications for opioid use disorder are safe, are effective, turn people's lives around,
and yet they have not been adopted as much by a long, long shot by either primary care physicians, by
clinicians in general and by the general public. Still, a lot of myths are out there that, "I don't want to
substitute one addiction for another. I don't want to go on medication."
Margaret Flinter ( 01:46 ):
And this is Conversations on Healthcare.
Mark Masselli ( 01:56 ):
Well, Dr. Levounis, welcome to Conversations on Healthcare.
Dr. Petros Levounis ( 02:00 ):
Thanks so much for having me in your program.
Mark Masselli ( 02:02 ):
Some really disturbing news came from the CDC and some provisional data reporting that more people
died from suicide in the United States last year than any other year on record. And now you've spoken
out in the past that when people are feeling suicidal, they're doubly adverse to seeking mental health
support. I'm wondering if you could tell us about the APA Foundation's Mental Health Works campaign
and what it intends to do?
Dr. Petros Levounis ( 02:33 ):

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Yes, our campaign has one major goal, to open up the conversation. Way in the past, we thought that
when you talk about suicide, you may be making things worse. We know that it's not true. The more we
talk about these matters, the better off we are. So opening up the conversation, having that first
openness with a loved one or with anyone whom you trust is just so essential.

Speaker 3 ( 03:04 ):
For the longest time, it was hard for me to even get out of the house, much less do a backside 180. It
took me a bit to understand what was going on, but eventually I learned I had anxiety.

Dr. Petros Levounis ( 03:17 ):
Of course, seeing a professional, seeing your primary care physician, seeing a psychiatrist is a great idea,
but the majority of people who start feeling depressed or anxious or sometimes even suicidal, they
would prefer to talk to someone other than a psychiatrist at first. So this is what the campaign's strength
is all about, to not just say there's one and only one path to finding help.

Margaret Flinter ( 03:46 ):
Well, Dr. Levounis, anxiety of course, is a big contributor to distress that may get people to that state,
and the US Preventive Services Task Force has now recommended for the first time I believe that
physicians screen all adult patients under age 65 for symptoms of anxiety. Are you and your members
seeing or are you hearing reports of an uptick in referrals coming from primary care and other physician
and other healthcare provider practices? Do you think this is going to be helpful?

Dr. Petros Levounis ( 04:19 ):
It is going to be helpful. It is going to raise awareness about anxiety disorders, but we have not really
seen the effect that you mentioned yet. Maybe too early. This just happened this summer, so we
haven't seen the uptick that maybe we will experience in the future, but more than the specific
referrals, it's once again in the spirit of opening up the conversation and making this diagnosis much less
fearsome than they used to be.

Mark Masselli ( 04:56 ):
I know you're very proud about being elected as the President of the APA. What an honor, and you've
chosen as the theme of your presidential year, Confronting Addiction From Prevention to Recovery. You
say you don't want to just move the needle on addiction, you want the needle to keep moving. I'm
wondering if you could share with our listeners what do you mean by that and how are you making it
happen?

Dr. Petros Levounis ( 05:25 ):
I don't remember ever having a presidential theme focusing on addiction, so I thought it was time to do
so. I'm an addiction psychiatrist myself. It's a major issue for our patients, for the general public. So I
thought it was time to choose addiction, prevention addiction, recovery addiction, treatment as a theme
of my presidential year. But this is 12 months, so there's only that much that one can accomplish in 12
months. We have four campaigns that we are unleashing during these 12 months, and we're very proud
of them, vaping, opioids, alcohol, and the technological addictions. But it is something that needs to get
going beyond this 12 months. And we already convened a group of like - minded organizations at our

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headquarters in Washington DC, and the spirit of this meeting is what can we do to sustain these
campaigns, to sustain these efforts beyond these 12 months?

Dr. Petros Levounis ( 06:33 ):
And I was so pleasantly surprised by how well aligned we are, all these organizations from OB - GYN,
obstetrics gynecology to internal medicine to the American side of addiction medicine, and we were
really, really very similar goals, very similar tasks, and I do have great hopes that the addiction recovery
and the prevention will continue beyond my 12 months of presidency.

Mark Masselli ( 06:59 ):
Wonderful.

Margaret Flinter ( 07:02 ):
Well, what you are saying, Dr. Levounis, certainly resonates with those of us who are in the primary care
space, certainly in the nation's community health centers, which is where Mark and I are primarily
focused because smoking, vaping, alcohol and opioids are really what is shortening the lives of our
patients and causing tremendous distress. So we are very appreciative you're taking that focus, but I
wanted to talk specifically about the vaping for a moment.

Margaret Flinter ( 07:29 ):
A study in the journal Drug and Alcohol Dependence noted that people with mental illness are more
likely to use e - cigarettes and to use them more frequently than people without mental illness. That's
exactly what I always said about smoking. Before there was such a thing as vaping that was certainly
well known, but many people see vaping as less harmful than cigarette smoking. How are you and APA
getting the word out about this as a real concern?

Dr. Petros Levounis ( 07:54 ):
Yeah, it is a real concern, exactly like you said. There's a myth out there that smoking cigarettes or
vaping should be the least of someone's problems if they have a mental illness, and that couldn't be
furthest from the truth. As you very well know, the majority of people who live with mental illness will
not die of bipolar disorder or schizophrenia or depression or ADHD. They will die from tobacco and from
vaping and from alcohol and one of those disorders.

Dr. Petros Levounis ( 08:32 ):
So we want to dispel that myth that, "Hey, if you're already mentally ill, who cares? Have a little fun,
have your vaping, have your cigarette." This is an absolutely terrible message that people have been
perpetuating.

Mark Masselli ( 08:48 ):
Well, that's such an important reminder to all of us. I'm wondering if we could switch a little to alcohol
use disorder. I'm wondering what you can share with us about some of the innovations you're hearing
about. We see a lot of benefits, and I think Margaret, we saw this from maybe the Veterans Affairs
working on psychedelic drugs for treating alcohol addiction when combined with psychotherapy. What
other interventions you think are promising in this area?

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Dr. Petros Levounis ( 09:21 ):
Yeah, the study on psilocybin by my friend Steve Ross is quite revolutionary for our field because here
you have a substance that has been viewed for decades, if not more as a major villain and part of one of
the worst addictions you can think of. And now it is being studied and shown in a preliminary fashion to
be helpful in the treatment of alcohol use disorder. So it is switching positions.

Dr. Petros Levounis ( 09:58 ):
We're not there yet. We haven't crossed all our Ts and dotted all our Is in terms of drug interactions, in
terms of long - term effects, in terms of pregnancy and so on and so forth. But the preliminary results are
quite encouraging in terms of psilocybin for the treatment of alcohol use disorder.

Mark Masselli ( 10:16 ):
Are there any large clinical trials going on in that particular area?

Dr. Petros Levounis ( 10:21 ):
There was the one that was published in 2022, and I do believe that there are more coming up. The
other thing about alcohol that we do need to mention is a shift in the appreciation of outcome studies
for alcohol use disorder. It used to be that only complete abstinence was something that we would
appreciate as a worthwhile outcome of any treatment study for alcohol. And in 2023, we very much
appreciate and respect decrease in heavy drinking as being another very desirable outcome of alcohol
studies. So we have shifted our research focus on alcohol as well.

Margaret Flinter ( 11:08 ):
Well, we look forward to learning more about that. It is such a prominent and common problem in our
patient population, really in the society at large. And one of the groups that we're very concerned about
are women and young women. We're reading that women, females in their teens and early 20s, the
data suggesting that they're reporting drinking more, actually getting intoxicated at higher rates than
their male peers, something that we maybe had not seen previously. And I'm wondering, as you try and
craft messages and policy, is there a targeted public policy approach needed that's specifically designed
to reach young women in the way that we've tried to reach other particular populations of focus?

Dr. Petros Levounis ( 11:57 ):
Yeah. Yes, we do. And the point there, which is very well studied, very well researched, very well
established is the concept of telescoping among women. And that has to do that, although it may not be
that there are as many women who start drinking heavily as men, once women start drinking heavily,
then from the early points of illness to the most severe form of illness, the process is very quick. And
that is of huge concern of course to us, and also greatly underappreciated because people just read the
studies of the major epidemiological studies and they say, "Hey, this is primarily a men's problem, not a
women's problem." And yet this idea of telescoping is particularly catastrophic for women.

Dr. Petros Levounis ( 12:52 ):
Adding to that, the other well - known fact that women tend to drink more in private situations, more
alone, so the opportunities for red flags go up are less than with men. Men tend to drink more in public,
and so hopefully there is a friend or somebody will see a catastrophe coming down and they say, "Well,
wait a minute here. Maybe there's something that we can do about it." While women tend to drink

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more at home and when nobody else is around. Again, I'm talking about in general here. Of course, a lot
of men and lot of women who are on the other side as well, but that is of great concern to us.

Mark Masselli ( 13:40 ):
I'm really fascinated by the work you're doing as editor of the book Technological Addiction, and you say
the book is really a wake - up call, alerting the medical community and society at large to the addictive
potential of technology. And you've talked about gaming being addiction as well as cyber sex, social
media texting, email and online auctions. I'm wondering, when do these activities reach the level of
addiction and what does treatment look like?

Mark Masselli ( 14:14 ):
I've also noted that we're seeing a lot of commercials now focused in on young people who are really
being addicted to social media, so I'll add that in as one of those areas that is this something that the
APA is also behind in terms of sponsoring advertisement or notifications about this?

Dr. Petros Levounis ( 14:36 ):
Yes. Yes, we are. And may I mention that we're having four campaigns this year, and we talked about
vaping, opioids, and alcohol, but the fourth one is on the technological addictions. So the vast majority
of people do engage with technology in 2023. I know I do, and I'm sure most of you do as well. And the
vast, vast majority of people are not going to have a problem with technology, not with internet gaming,
although we may play some games, we may engage in texting, emailing social media and so on, but
there's a very good chance that we're not going to have any problem with it. Either recreationally or
professionally, it is part of life.

Dr. Petros Levounis ( 15:22 ):
However, there's a small group of people, maybe 3%, 4%, 5% who will cross the line and be on the other
side. And what we see with these patients is something very similar to what we see with people who live
with substance use disorders. We see tolerance. We see people needing higher, higher amounts of the
same activity in order to sustain the same level of excitement. We see withdrawal. We see people
abruptly stopping using an internet game and becoming irritable and depressed and anxious and
suffering from insomnia, classic symptoms of withdrawal. We see people trying to cut down and not
being able to do so despite the fact that they recognize that it's not good for them. The classic major
blocks of the assessment and diagnosis of addiction.

Dr. Petros Levounis ( 16:23 ):
Consequences, relationships going south, hobbies being ignored, professional responsibilities being put
aside, medical consequences. So these are the things that we look for when we do give the diagnosis of
a technological addiction. Internet gaming is being appreciated, is a formal medical diagnosis by the
International Classification of Diseases and may very, very well be part of the DSM - 6 of the American
Psychiatric Association.

Margaret Flinter ( 16:57 ):
Go ahead.

Mark Masselli ( 17:00 ):

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I just want to maybe follow up on Margaret, thinking about... We've had Dr. Vivek Murthy on talking
about the epidemic.

Margaret Flinter ( 17:07 ):
Read my mind.

Mark Masselli ( 17:08 ):
Oh, really? The epidemic of loneliness and isolation. I'm wondering if those numbers are starting to
change in the COVID environment? What are you seeing? Certainly, I think about the social media
impact on young people, probably on all of us because of COVID. Is that an inflection point where we
have to recalibrate and start thinking about the size of the wave that's coming at us?

Dr. Petros Levounis ( 17:39 ):
Yeah, that's how I see that. I see that there's going to be a small number of people who actually may be
bigger than 3% or 4% that I just mentioned before, who actually will meet criteria for medical condition
and will need professional help. We do know that cognitive behavioral therapy, motivational
interviewing, maybe even mindfulness would be quite helpful for people who do suffer from this
medical condition. And then there is the general public. There's the rest of us who engage in social
media, and to me, that's a social experiment. We're not quite sure how it's going to end up.

Dr. Petros Levounis ( 18:17 ):
I see my 12 - year - old niece engaging with social media and having an entire world that is virtual, which I
couldn't even fathom of having at her age. Will these friendships be at par, better, worse than the
friendships that I had when I was at 12 years old? I'm not quite sure. I think that this is something that
has to play out and find what we're going to see some years down the line. What we do know is that
there's some significant positive effects of engagement with technology. For example, older adults are
particularly vulnerable to scams and online shopping and internet engagement with people who may
not have their best interest in mind. So my 12 - year - old niece will have much better antibodies against
those scammers than perhaps quite a lot of our older adults.

Margaret Flinter ( 19:30 ):
I would just add Mark, as you were saying, Dr. Vivek Murthy, certainly somebody who has deep concern
with this issue, and particularly I'd say about children younger than 12 who are on social media, who are
being exposed to things which seem intentionally designed to keep them engaged and for periods of
time that may call out other activities more healthful perhaps for that age group, and maybe we can
come back to that if we have a few minutes, but I did want to make sure to give you an opportunity to
talk about another of your key areas that you're focused on, and that is opioid addiction, which we have
lived through from the beginning through the promotion of the opioid drugs, through the response to
the epidemic, and of course, we're still left with the huge loss of life.

Margaret Flinter ( 20:21 ):
I think you had a poll that showed that Americans strongly favor improving access to treatment over
imposing stricter punishments, legal punishments to address the problem. Can you share a little bit with
us and our listeners about what insights you'll be bringing to this issue during your term?

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Dr. Petros Levounis ( 20:39 ):
Yeah. When we chose our Addiction Prevention to Recovery campaigns, our guideline was to find areas
where we'll have the biggest gap between what we're sure about, what science has pretty definitively
concluded on and what is appreciated by the general public. The greater the gap, the more enthusiastic
we are about our campaigns. Opioids is exactly one of those areas. We do know that medications for
opioid use disorder are safe, are effective, turn people's lives around, and yet they have not been
adopted as much by a long, long shot by either primary care physicians, by clinicians in general and by
the general public.

Dr. Petros Levounis ( 21:34 ):
Still, a lot of myths are out there that, "I don't want to substitute one addiction for another. I don't want
to go on medication. I just want to be clean. I want to detoxify," all these things that we have tried and
we know that they're not effective, that they are more trouble than good, and we do have the answer.
To me as an addiction psychiatrist, there are so many substances for which we do not have any
medications. For example, I'm thinking about the stimulants, cocaine, crystal methamphetamine. We
have wonderful psychosocial interventions, we have wonderful psychotherapies that can address these
conditions, but we do not have a medication. And then we do have medications for tobacco use
disorder. We have medications for opioid use disorder that work extremely well, and we do not use
them. It's such a shame.

Mark Masselli ( 22:28 ):
Yeah. I want to just get a little away from the addiction and come back to it though. I was thinking about
the impact that long COVID is having across the society. I know we've just had Dr. Lenore Horwitz from
your old stomping grounds, NYU, who's doing large clinical trial on long COVID. I'm wondering if there's
any engagement with the APA or any of your colleagues are engaged in this because the mental health
component is so critical, the levels of anxieties have increased? I'm just wondering if you have any
observations or intersections with the work that's going on and will be going on for a long time, focused
in on the impact that long COVID is having on society?

Dr. Petros Levounis ( 23:23 ):
Yeah, we do see a neuropsychiatric sequelae of COVID infection part of long COVID, and we're
particularly concerned about that. At this point, the data is significant, but it's not very specific. There
are a lot of symptoms that mimic other psychiatric disorders so we're not quite sure of what can be
attributed directly to the effects of the COVID infection. What I'm saying here is that we have seen an
increase in anxiety, we have increased in depression across the board with the pandemic, but this may
very well have been the consequences of the stressful situations, financial and social and professional,
and all kinds of stresses that people have experienced with the pandemic. Some of it may very also be
the direct effect of the COVID infection, and that's exactly what we try to tease out and become much
more confident when we talk about long COVID and its implications.

Dr. Petros Levounis ( 24:31 ):
I want to add the third concern that we have there. It's actually not a concern. It's actually a positive
thing, and that is that the pandemic has brought in the forefront the conversation about mental illness.
This is something that we were not really prepared for. Right before the pandemic people had started
appreciating and discussing mental illness, but certainly the pandemic accelerated this awareness. And
for that, of course, we are particularly excited about.

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Mark Masselli ( 25:10 ):
I want to pull the thread a little on that concept. We've been engaged in providing school - based health
services for about 30 years. In mental health, we've always been saying what we want to have happen is
to normalize the use of mental health clinicians, but today we have more and more schools calling us up
and saying, "You've got to come in now," which we used to start with dental and then go to medical, and
behavioral health was the last rail, but now, I think really to your point is resonating across the country,
people are demanding.

Dr. Petros Levounis ( 25:48 ):
That's exactly what we're experiencing as well. You couldn't have put it better. We used to scream from
the rooftops about, "Wake up. Mental illness is such an important issue." And people were like... We
would land on deaf ears, and all of a sudden the tables completely changed and people are screaming,
"We need more help. We need support. We need services. We need this and this," that we haven't been
prepared to respond to this kind of demand. So our work cut out for us to figure out how we can
respond to this incredible demand that we see everywhere around us.

Margaret Flinter ( 26:24 ):
Well, I'm so glad you raised that point, and Mark addressed an important way that we create access
through school - based health centers, but access to psychiatry, to psychiatrists, to psychiatric nurse
practitioners, to therapists obviously is huge. And if we have time, I'd love to talk with you on your
thoughts of what we're doing to train enough people, because certainly in the primary care space,
recruiting psychiatrists is one of the most difficult positions. But even if we were able to address that
issue, we have the challenge of the health insurance plans and the restrictions. Mark, we had former
Congressman Patrick Kennedy on the show to talk about health plans and how do we hold them
accountable to the requirements of the Mental Health Parity and Addiction Equity Act? And I wonder if
you might just tell us some of your tools and efforts to ensure that health plans comply with the law for
psychiatric mental health treatment, but also substance use disorder treatment?

Dr. Petros Levounis ( 27:22 ):
Yeah. I was on the phone with Patrick Kennedy a couple of days ago, and I was delighted to see how
extensive a plan he has to address exactly what you're saying. And of course, the APA is more than
happy to help in these efforts. I would say the APA does quite a few things quite well, but our
engagement with policy is probably one of the marquee components of the America Psychiatric
Association. So we do partner with other organizations. We do have the group of six, as you probably
know, with family medicine and internal medicine, OB - GYN, pediatrics, osteopathic medicine, and
psychiatry. So we come together. We mentioned that we have 38,000 members, but altogether as a
group of six, we have over 300,000 members. And so when 300,000 physicians are talking through our
representatives, then the Hill starts listening. So we're quite optimistic here that by combining our
voices we will have an impact.

Mark Masselli ( 28:33 ):
Let me just get to one last area, just again the breadth of the APA. You have a webinar about how
generative AI and related technologies may affect mental health and the practice of psychiatry and how
to recognize the strengths and risks of AI driven technology. I'm wondering what your feelings are about
AI and any advice that you might want to share?

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Dr. Petros Levounis ( 28:58 ):
Yeah. I'm quite positively predisposed to AI, and I think that there's a lot of promise there. I do a lot of
CBT, cognitive behavioral therapy with my patients, and what I do is I give them homework and I give
them tables to fill, and I give them Excel sheets so that they can record their feelings and put grades and
rate their cravings and all that stuff that are incredibly amenable to AI, to apps, to things where people
can record their activities and their thoughts and their feelings, as well as follow their progression
through time.

Dr. Petros Levounis ( 29:40 ):
What is missing is the intersection with a clinician. There are some apps that advertise. You don't need
the clinician at all. You can do it all by yourself, and we do not think that this is effective. We do think
that you need a human being to be involved in some capacity, and these electronic devices can be
wonderful adjunct, but they cannot replace the human being.

Dr. Petros Levounis ( 30:05 ):
On the other end of the spectrum, there are some apps that require the clinician to be available 24/7 to
the patient, and that is unworkable as well. So somewhere in - between from not needing the clinician at
all to having a clinician 24/7 is the sweet spot where we're striving to find out exactly how we will
combine the personal touch of a trained therapist with an app.

Margaret Flinter ( 30:35 ):
Well, Dr.Levounis, I want to thank you so much for joining us, and I'm just hoping we can extend an
invitation to do it again sometime soon because we have a lot more questions that we'd like to ask and
engage with you on. And we also want to remind anyone who's in need of mental health support to call
988. That's the new Suicide and Crisis Lifeline. It can be a huge help to you. And thanks to our audience
as always for being here. There's more online about Conversations on Healthcare, including a way to
sign up for our email updates, the address, chcradio.com.

Margaret Flinter ( 31:07 ):
Dr. Levounis, thank you for your leadership for all that you're doing, and we look forward to speaking
with you again in the future.

Dr. Petros Levounis ( 31:14 ):
Thank you so much.

Mark Masselli ( 31:15 ):
Absolutely.

Margaret Flinter ( 31:19 ):
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