 Okay, so over the next 55 minutes, what I'm going to try and do is talk about some of the work that we've been doing. And over probably I can do work in this field for about 25 years, but I'll talk about some of our more recent work. And sort of how we've tried to understand the really complex phenomenon that is suicide and suicidal behavior. It's a stark reality that every year globally, about 800,000 people lose or struggle to live. And countless more than that. Literally every day we think there are maybe 10 times that number who attempt suicide. So really it is a huge public health priority and indeed suicide is the leading killer of men under 50 in our country. It's really important that we tackle and try and understand it. It's what I will do. In terms of mine is, I'll say a bit about background to the complexity of suicide, and then I'll focus in on the IMV model so the integrated motivational volitional model that I developed, and then talk about some of the research that we and others have done to try and understand the concepts. And you'll see there's three parts to the talk. The first bit is a sort of description of the key components of the model. And the second bit is looking at what I see is one of the key challenges in the field, which is lots of people have thoughts of suicide transition from thinking about suicide to attempting suicide. Our best estimate is it's about a third of people make that transition. So we're trying to focus in on what are the key factors we think help us understand who is more vulnerable, who is more likely to act in their thoughts of suicide. And then the third bit I'll talk about is some recent research we've been doing, given obviously COVID-19. At the start of the pandemic we launched a large scale study across the UK to try and track people's mental health. I'll report what are our key findings from the initial phase of lockdown, which I think is some media coverage over the last couple of weeks. So that's a broad context. So we just jump in straight into the complexity. And this is a model, a biopsychosocial framework or model that we published last year. We have a work by Gustavo Terecki, a psychiatrist. His work in McGill in Montreal. But what I really want to highlight here is really the recognition that if we're to understand suicide risk, we have to appreciate that suicide, although often media, I think it's often covered in a very reductionistic way that there's one reason why people kill themselves. And that often is people kill themselves because they're depressed. And indeed, although depression is an important part of the puzzle that leads to suicide, depression is not the reason people die by suicide. And indeed, it's estimated that all those people who are treated for depression less than 5% of people who are treated for depression actually end their life. So what that recognizes is that yes, suicide in Western countries usually occurs in the context of the mental health problem, but mental health problems are not a sufficient cause or sufficient explanation. And as you can see here from the figure, if we're looking at suicide risk, we have to look at early life adversity and I'll come back to that later in the talk. Early life trauma and how that can influence our well-being and our vulnerability and then look more broadly at these sort of developmental factors. We've done a lot of work on some personality factors. So for example, we've done a lot of work on this idea of a particular type of perfectionism called socially prescribed perfectionism is associated with increased vulnerability to suicidal thoughts and suicidal attempts. And what socially prescribed perfectionism is, is some of us, and I'm one of them has really high levels and was really concerned about the expectations of others around us. And that whose expectations that every day is an opportunity for repeated failure. And every day is an opportunity for us to think that we've failed to meet other people's expectations of us, which we then internalize a self criticism, and we're caught in a sort of negative cycle of negative thoughts of ourself and the world and the future. But what I really want to focus in them is the recognition you can see psychopathology is here is what I've mentioned in terms of recognizing that there is obviously a mental health context in mental health. But what I'm really going to focus in on today is really what I see is more proximal psychological factors. So one of my key take home messages from tonight will be that although suicide and to understand suicide risk, we have to recognize complexity, the biological complexity, the social context, the psychological context. I have argued that suicide is ultimately a psychological phenomenon, because for basically in terms of globally 800,000 people each year who die by suicide, basically, that perfect storm of factors comes together such that an individual views or future is so bleak that they see suicide as the ultimate solution to their mental pain, and that they feel that they're trapped in this sense of mental pain. So I'm really going to focus in on the psychology because I think it's ultimately a psychological phenomenon affected by all these different complex factors, and indeed that's where I let my thinking when I developed the integrated motivational volitional model. So that's the broad context. And so to say that I've been working in this field since the 1990s, and then about maybe about 10 or 15 years into my journey, my suicide research journey. In 2011, I published the integrated motivational volitional model. Now, it was published first of all in 2011, and then with my colleague Olivia Kirkley, we updated it and refined it a little in 2018, and it's a 2018 paper that you see here. But I suppose it was my attempts at the time to bring together the different theoretical perspectives because other people have been trying to piece together over many years in a sort of framework to understand the psychological, the social, the biological, and cultural influences and suicide. And then V model in 2011 was my attempt to do so. So what I'm going to do now is just give a brief overview of the key components of the model, and then move on to some of the research that we've been doing over the last number of years with my colleagues at the suicide behavior research laboratory and then nationally and internationally to try and address some of the key questions that arise from the model, but crucially, to help us better understand who's most vulnerable. Because if we can understand why and when people are most vulnerable then we can develop interventions to hopefully prevent suicide. So this is the IMV model, integrated motivational volitional model, and there's a bit of a mouthful so we just go for IMV for short. As you can see here it's in three parts. So on the left hand side here, we've got the premotivational phase, and that left hand bit is like the sort of the background context in which suicide with thoughts and behavior may emerge. So first of all we've got there we've got diathesis which is just another word for vulnerability factor. And those vulnerability factors can come in many different forms. So some of those vulnerability factors can be biological. So for example, we know that there's low levels of serotonin and it's metabolites and transporters are associated with vulnerability to suicide. They're also associated with a whole range of other issues and problems, but it's just one particular vulnerability, or you could have a personality type vulnerability factor, and I mentioned one already this idea of socially prescribed perfectionism. The second bit of the premotivational phase is environmental influences. And the stark reality is that people who died by suicide although suicide effects are can affect people across the socioeconomic spectrum. It disproportionately affects people at here towards the lower end of the of the socioeconomic spectrum. And indeed in Scotland we know that depending what statistics you look like the rate that the risk of suicide and basically the most disadvantage there is, compared to the most disadvantage there is depends on some ways you can do the analysis, but at least two to three fold right up to 10 full differences, obviously be much more common and the most disadvantage there is. And then the last bit is negative life events we know that people who attempt suicide or died by suicide experience at this proportionate number of negative life events and I'll return to stress and negative life events later in the talk. So for the purpose of tonight, I'm going to focus in on the key I think is the key components of the model. So in a very parsimonious way, the second bit of model or the motivational phase is trying to understand the emergence of suicidal thinking or the emergence of suicidal ideation. And in a very straightforward way the argument is that suicidal thoughts emerge in situations in which people feel either defeated and or humiliated from which they cannot escape. And ultimately the key driver to suicide risk is this sense of entrapment. And this entrapment is this mental pain that an individual feels it cannot escape from. So it's a contemporaneous experience of both defeat and humiliation from which he cannot escape. Now other things like shame and loss and other sort of negative emotions can feed into that sense of defeat and humiliation, but it's that ultimately the key driver is that sense of entrapment. So that's in a very parsimonious way. There's a range of other psychological factors here, which are all implicated and as we move from defeat through to entrapment through to suicidal ideation. But again, if you're interested to learn more about the model, if you go to our website at suicideresearch.info, there's much more detail on the IMV model, including a range of sort of videos and podcasts and other resources which explain in more detail some of the other factors. And then the third bit of the model is comes back to this issue I mentioned at the start of the talk. This idea that we know that lots of people experience suicidal thoughts. But thankfully the majority of people don't make that transition don't cross the precipice from thinking about suicide to attempting suicide. So according to the model is third phase, the volitional phase is key. It's key to understanding that transition, or we would describe it in psychological terms as the sort of behavioral inaction, so that it's going from thoughts to acts of suicide. And so, according to the model, when I updated the model with Olivia in 2018, we define this phase in much more detail. But I'll come back to this transition in the second part of my talk. But really, there are eight, as you'll see, eight key, what I describe as volitional factors or volitional moderators, the presence of which increases the likelihood we move from thinking about suicide to attempting suicide, but I'll come back to that. And what I want to focus on now for a second is some of the data that we have in really understanding the sort of central portion looking at defeat and entrapment and so on. So the key message here is entrapment is central to the sort of suicidal process, and we need to maybe understand it better. And so basically, we've done lots of different studies looking at different aspects of the psychology of suicide, different aspects of these sort of entrapment processes and defeat and humiliation and so on. So what I want to focus in on is one study, which is front and center here, which is this four-year study we did with colleagues and Edinburgh and Nottingham and Oxford, in which we tracked what we often do in some of our clinical studies is we try and track people over time and try to determine whether some of the factors we think are important in predicting suicidal behavior over time, we try and investigate, are they actually important? Because if we can demonstrate that they are important, then that says to us, we need to try and intervene and target that particular factor. And this study is focusing, as you'll see, in on entrapment. In this study, people in, this is conducted in Edinburgh, people who presented at the hospital following a suicide attempt, one of my team will have assessed them on a whole range of psychological measures and clinical measures, including depression and entrapment and so on. And then over time, we're able to confidentially and anonymously track individuals over the next four years to see whether individuals attempted suicide or sadly died by suicide. Because what we're trying to establish was, if my model is correct, entrapment should be really important in predicting those individuals who attempt suicide. So this is our key findings in this study, this graph just represents those individuals in green over the next four years never attempted suicide again, or never died by suicide. We're a peak group or individuals who sadly were hospitalized again. And what this graph just illustrates on the horizontal axis and each of these factors that people when we saw them in hospital, who were more suicidal, were more depressed, who were more hopeless, defeated and entrap. Unsurprisingly, perhaps, they all predicted, statistically predicted the increased likelihood of attempting suicide in the next four years again. And what was important, though, was when we asked which of those factors is most important, we found two factors emerged. First was past behavior. So single best predictor of whether somebody attempts suicide in the future is whether they've attempted suicide in the past exactly the same as any other behavior. So that's exactly what we find here, but I can't change somebody's past, of course. Another factor which emerged was entrapment. So when we assess levels of entrapment in the hospital, maybe this is usually within 24 hours of a suicide attempt, those levels of people, what people told us in terms of levels of entrapment predicted, repeat suicidal behavior over time. So the take home message from this study and countless other studies that we and others have been involved in is, is it working with somebody clinically, we need to be trying to target this sense of entrapment, entrapment is the sort of pernicious psychological factor, which is maybe driving the suicidal thoughts that we're trying to reduce. These are just some other data from other studies which tell the same story. But what I want to just draw your attention to here are, so don't worry about the statistics is one of the things about the model the model argues is that people who are feeling defeated. What is dangerous is if you feel defeated, and then you're trapped. And then it's entrapment that leads you to becoming suicidal. So we describe that obviously as a mediating pathway is when trapman is a mediator, or the bridge between defeat and suicidal thinking and we find this in this top one, Karen Wellerall, my, my lab. So Karen, this is data from university students, and then the figure below is Rebecca Owen and colleagues at Manchester University. And this is a group of patients with bipolar disorder. But the key message here is you still see the same pattern, defeat to entrapment and entrapment to suicidal thinking. And then you see it highlighting the importance of entrapment. And then they're bringing this closer to home. A few years ago, we conducted the Scottish Wellbeing Study. And the Scottish Wellbeing Study is this longitudinal study, as you can see here, a nationally representative sample of young adults. And these are some data we just under revision with a journal at the minute. But could we predict suicidal thinking over 12 months. And, and basically, as you can see here with three, three and a half thousand people at baseline. And then 12 months later we got a good follow up with 71% of the sample. Now all the sensitive questions are in suicidal thoughts and so on, we're all completed on the computer. So we've got confidence in terms of the people's answers to these. But again, in terms of the model, key factors that we're looking to see what predicts suicidal thinking over time. What we can see here are. So again, forget about the statistics, but the key messages are in bold. So when we look at see what predicted suicidal thinking at 12 months or 12 months after seeing us for the first time. So unsurprisingly, how suicidal somebody was when we saw them at baseline was a significant predictor of how suicidal they were 12 months later. So that's no surprise. So again, the same idea that the best predictor of future suicidal thinking is your past suicidal thinking. But again, when we do this multivariate analysis to other factors he measures. One is an aspect of entrapment called internal entrapment and perceived burdensome. Again, these are burdensome. This is also in the IMV model. It draws on work that Thomas Joyner and other psychologists in the United States talks about and his own model of suicidal interpersonal theory. But what I want to just highlight here is this sense of internal entrapment and there's lots of studies now, which show that internal entrapment is much more dangerous for your mental health than external entrapment. So what is internal and what is. So internal entrapment is a mental pain. These thoughts of people who are suicidal often grapple with which is I'm worthless. I'm a burden on others people be better off. And that life is not going to get better that cyclical cyclical. And that's much more dangerous we think than external entrapment and Mike Internet is saying Internet is unstable so I'm hoping you can still hear me. And external entrapment external entrapment is when you trap effectively be life circumstances and indeed it could be that you've lost your job and you don't see any prospect of getting another job or your relationship is broken down and you don't feel that you'll find love again or whatever it may be. And I said here is when we're trying to predict suicidal thinking over time entrapment is key burdens on this are key, and this is over and above when we, because although depression is important in the sort of background in the mix of understanding suicidal risk and statistical terms is not a specific enough marker of risk. So that's sort of lots of sort of data on different studies with different populations clinical populations and non clinical populations in which we try and understand suicidal risk. And these are just the last slide again drawing from the, the Scottish wellbeing study where we see we see the same pathway which I mentioned earlier, the fate to entrapment to suicidal thinking. Hopefully we'll give you some. The fact that the core of the central bit the motivational phase of the IMD model is mean there's empirical data to support it and the central importance of entrapment. And the question is, well, how do you assess entrapment I talked about what internal is. I talked about what external entrapment is. When we assess entrapment we normally use 16, 16 items scale, which was developed by clinical psychologist Paul Gilbert and his colleagues Stephen Allen. And that's all well and good. And it's, it's really kind of external entrapment and the data I've just talked about all use that measure. But if you're going to work clinically with somebody who's in front of you and you're concerned about and you're trying to see how trapped they are. The 16 items isn't, isn't particularly helpful. We need a briefer measure. So what we did is the level work at Dirk de Burr in the Netherlands and other colleagues and what we basically did was, we, we developed a four item version of entrapment the short form entrapment short form scale effectively. But what's really interesting is, even if you just use the 14 items, the correlations are really, really close. So this correlation here of 0.94 in the clinical sample says a clinical sample of almost 500 people who'd self harmed. And so that 0.9 correlation is the correlation between the brief four item version and the 16 item version. So really we're losing very little explanatory power if we use four item version. So then the questions are, but what are the, what are those four items? Again, for those of interest, here are the four items. So there, so again, so I often have the feeling that I just like to run away or I feel trapped inside myself and I feel them in a deep hole I can't give out. So those are the four questions which are tapping entrapment in the, in our, in our scale and we're hoping them with, we just published this short version of it, that it will hopefully increase the likelihood, or extend the likelihood that will be used in clinical context, as well as in other research studies. So that's all I'm going to say about this sort of the motivational phase of the model, so the defeat and entrapment and so on. What I want to do now is return to the, I posed at the start, this challenge that all those people who think about suicide about a third will make the transition from thinking to attempting suicide. Essentially, if we have a loved one or a family member or friend who's having suicidal thoughts, we're trying to, it's obviously frightening, and you're trying to then ascertain who is more likely to act on their thoughts. It's really important to state that sadly, although there have been huge advances in our understanding of suicide, our ability to predict suicide is still no better than chance. And that is in part to do with the fact that although every single suicide is a trap, suicide is global each year, 6,000 in the UK, 7,800 in Scotland, that statistically there are rare events and statistically, in terms of rates per 100,000, there's about 10 people in every 100,000 people will end their lives in the UK. So you're trying to basically only, are you trying to identify the 10 people out of the 100,000 who are at risk. But that's one of the founding sort of fathers of modern suicide research. Edwin Schneidman talked about you're trying to predict death day, not only are you trying to predict the person who's most likely to die, you're trying to predict the person who's most likely to die. So it's really, really challenging. But in our attempts to understand and move and improve our understanding, theoretical models like mine and others we hope will help us move forward in that, and that really important challenging task. So what this is this slide is, if you think back to my model many slides ago, the right hand bit of the model, the right hand bit of the model is a volitional phase was called the volitional phase. What's simply done here is blown up the, the volitional phase we can see the eight key factors as you can see there are eight factors. The argument is that the presence of somebody's feeling suicidal having suicidal thoughts that the transition from think from thoughts of suicide to suicide attempt to go from the blue through to the sort of peach color is increased the more of these middle phase factors, more of these volitional factors you have. So we'll talk us through a few of these and then I'll return same idea with some data. So so in retrospect, some of these are not that surprising in that they make sort of common the common sense. But what I try to do is put them in a framework which helps us understand who might be more vulnerable. Again, we can then targets interventions along some of these, these eight volitional factors, because these are the key so these eight factors. I would argue are the key factors which govern the transition from thinking to attempting suicide. So the first then, again, no surprise. If I am thinking about thoughts of suicide, I'm much more likely to make the transition from thinking to acting on those thoughts if I could access the means of suicide. And indeed, if we look at public health interventions, so the most robust evidence we have globally for what works to prevent suicide is restricting access and restricting access can be. So if you think back 20 years ago in the UK in 1998, more than 20 years ago 1998, the legislation was changed so that you couldn't buy paracetamol or other analgesics. And you could only buy them sorry and blister packs of 16 that's when that was introduced, and you can only buy two packets without seeing a pharmacist, and that's legislation now. And that change from being able to buy countless tablets and paracetamols and jars, and whatever, whatever you hold lots of tablets in, and that changing to blister packs has been shown to reduce the number of suicides. So that huge or things we do in terms of access to areas of concern, adding catalytic converters to cars reduce suicide risk, there's a whole, there's a number of them. So the restricting access to means is really important. Second, basically the extent to which somebody is actually formulated a plan. How and when and they're going to actually attempt suicide increases unsurprisingly increases the likelihood that somebody acts in their thoughts and indeed we've done some basic some brief interventions based work, looking at how we can do work with safety and other types of psychological interventions to which target that planning phase to hopefully interrupt the suicidal thoughts, so they don't go from thoughts to acts of suicide. Third, exposure to suicide or suicidal behavior. So that's knowing somebody else will be close to you who's attempted suicide or died by suicide, your statistical risk is increased if you've lost a loved one to suicide. And I have somebody who's sadly lost two people my life to suicide. I'm high up on this in terms of a risk, another risk factor that I have. Now it's really important to highlight that although that's a statistical risk factor, the overwhelming majority of people who have been briefed by suicide or lost a close friend to suicide, they'll never become suicidal will never attempt suicide will never die by suicide, but is a risk factor. Next, impulsivity again, no surprises perhaps. Thoughts of suicide are impulsive, much more likely to act on your thoughts. And then our physical pain sensitivity or tolerance and fearlessness about dying. They're comprised of what Thomas Joyner who I mentioned already talks about is having the capability for suicide for you to act on your thoughts of suicide. For many people you have to overcome the fear of dying, you have to overcome, you become fearless about dying we know that fearlessness about dying comes and goes waxes and wings and with higher levels of fearlessness and much more likely to act on their thoughts. Physical pain tolerance are also more likely to act on their thoughts and indeed mental work on these aspects. And then the second last one is mental imagery. If people who actually picture themselves dying are dead and much more likely to act on their thoughts. And then the last one as again I mentioned a few slides ago, best predictor of future behavior is past behavior. So again if your thoughts are suicide and you previously attempted suicide, you're much more likely to act on your thoughts. So according to the model according to my model, these eight pillars of behavioral and action, they're the key to understand this transition from thinking about suicide to attempting suicide. So what I want to do now is show you some data we've got from the Scottish well being story, again, which I mentioned earlier, Scottish well being story is identifies you can see here are respondents into three groups. People who'd never been suicidal. People who thought about suicide, but have never acted on their thoughts. And then those individuals who actually attempted suicide. So again, what we can simply do then is if according to my model, according to my model, if I was to just focus in on the people who think about suicide so the ideation group and compare them to those who've attempted suicide. Shouldn't differ on my motivational factors like defeating entrapment. Shouldn't differ on the volitional factors like impulsivity and exposure and so on. Because remember the volitional phase, the volitional factors are key to behavioral and action key to this differentiation between thinking about suicide to attempting suicide. In the next slide and just literally going to focus in on the ideation group, and the attempt group, and let's go through each of the variables just very quickly, and you'll hopefully be able to detect a pattern, which is consistent with my model factors on the left hand side. First of all, just to highlight that unsurprisingly, the people who attempted suicide are significantly older and significantly more likely to be female. So although suicide tends to be characterized as a male phenomenon, because three quarters of all suicides are by men, non fatal suicidal behavior tends to be much more is much more likely to be female so they there's no surprises here. But crucially though, it's, there's no difference in depressive symptoms when you do these multivariate analysis. So it's not that the people who are more likely to act in their thoughts that's not explaining the difference between thoughts, the ideation group, and the attempts group. And what we've got here are these are factors all driven or derived from the middle portion of my model, my model. And so they're all important in the suicidal process. But my argument is they're not important in understanding the distinction between thoughts and attempts. And indeed that's what you find when you do the statistical analysis. There's no difference between those groups. Remember, the model says that volitional factor volitional phase factors are where differentiation is and that's exactly what you find that people have attempted suicide are significantly more hope or significantly more impulsive. There's significantly higher levels of this capability for suicide. This is measure of fearlessness and physical pain tolerance, significantly higher levels of this mental imagery around dying and death, significantly more likely to know a friend who's attempted suicide than those who just thought about suicide. But surprisingly, there was no difference. And we thought there might be a difference between the exposure and having a family member who's died by his attempt or family member who's died by suicide. And the reason we think there was no difference here is because this is a young adult population remember it's 1834 year olds. And because, and I think in that age group you're much more influenced by your peers rather than your family, but we need to replicate this. But the key take home message from this slide. And again, all the papers all the published papers here are, if you're interested to know more are all available on our website suicide research dot info. So, but the key take home messages the volitional phase factors in thinking with suicide and attempting suicide. Data I've just shown from Scotland. We see exactly same pattern of findings with data that Katie Dingra collected in England, you don't worry about the details just trust me, we find exactly same with English students. We also find exactly the same we look at adolescent self harm was not explicitly suicidal intent. There are very similar findings there. Again, that's a large scale sample of you can see are over 5000 kids, young people from. These data were from. So again really convincing I think of the importance of these volitional phase factors. And this is actually still with work led by Becky Mars at Bristol. Again, this is part of this big is what's known as the ALSPAC cohort study this even in Somerset and birth cohort study which people have been followed, families being followed for a long time. And what they've got some factors which are pertinent to the INV model, but what we can in this longitudinal study, we've been able to show is this idea of exposure or other past self harming behavior, or key predictors to future suicide attempts amongst adolescents. Okay, so that's the sort of the, the all I want to say about these sorts of studies so try to bus for me to try and recap. But it goes for is the importance of this, the factors that leads to the emergence of suicidal thinking. And then this bit is really focusing in on our sort of epidemiological research, which we're trying to understand this transition from thinking to attempting suicide. What I want to move on to now is something very, very different than some of the experimental base work. At the very start, we look at the model on the left hand side of the model, and the pre motivational phase we obviously had negative life events and stress. And one of the things we know for certain days, the people who attempt suicide, people who died by suicide over the course of their lifespan, both in early childhood, as well as throughout adulthood, they tend to experience significantly negative life events and that and remember if you experience negative life events, we need cortisol, the stress hormone to be released. And so we need cortisol is the fight or flight hormone. We need cortisol to prepare us to deal with what life's throwing open is. People are experiencing more negative life events. So the cortisol system is repeatedly for the stress system that HPA access is being repeatedly activated. And one of the things I'll show you in this experimental study that we did was keeping without this idea of trying to understand the difference between people who think about suicide and those who attempt suicide. What we're interested in here was saying, well, actually, I wonder, is cortisol is psychophysiology different. And is there and can we better understand the difference between thinking about suicide and attempting suicide in terms of cortisol. And our hypothesis, as I'll explain in a second, is this idea that because the stress system has been repeatedly humbled effectively. And that basically becomes dysregulated, it stops working as effectively and it becomes often described as a blunted cortisol response. So when we encounter a stressful life event, we will cortisol to be released. So it's, it is nice, released, and then it decreases to you. But when the cortisol system isn't working as well, you often see this flatter response. And it's that flatter response or the blunted response, which is problematic, because it's not preparing the body effectively to deal with the threats in the environment. And we also know that cortisol is implicated in decision making cortisol is implicated in problem solving cortisol is implicated in a motion regulation, three things, which are also implicated in the decision sadly to attempt suicide or die by suicide. So this is work that I've been doing in collaboration with an identical twin brother. And as you do, so Darryl who's a professor of health psychology or professor of psychology at Leeds University. And Darryl is a stress research because this is work I've done in collaboration with him. And we worked together quite a while. And I love this slide. I don't really care if you don't. I think it's amusing. This is our collaboration then and that's us as as we in as we in and then obviously as more recently, and our continued collaboration. Okay, so getting back to the sort of nitty gritty of the presentation so it's this experimental study, and we're looking what's known as cortisol reactivity. And the laboratory setting is what we do is, we bring people into the lab, and there's different experimental ways in which we can induce stress in the body. And one of those ways is what's known as called the Maastricht acute stress test, or the mast. Another mouthful is this combination of getting people put their hands in cold water, whilst having to do this pretty complicated. It's something like started at 1117. And you have to count back in 13s, I think the task. And if you and you think you're being video recorded. If you're getting it wrong, you have to go back to the beginning. So it's pretty stressful. And, and, and the source noted this is completely informed consent obviously people are told the nature of the task in advance. And there's no adverse effects, but what we do know is doing those combination of tasks of water task on the arithmetic task activates a stress system activates a HPA axis, and we can then assess cortisol. And how they assess cortisol isn't our saliva. So we give people swabs. And we can then, as you will see in a second, assess cortisol over the duration of the study. So we look at the study design. This is a very different one is we're bringing people into the lab. This time with different with people with different suicidal histories. So good individuals here with no suicidal history at all. Then we've got people who think about suicide but haven't acted in their thoughts, and then people who have attempted suicide. So again, our key thing here is we're trying to look at an analog sort of way trying to understand the mechanisms what's associated with the risk of a suicide attempt in this laboratory setting so we can then hopefully it helps us understand more generally what might be going on in the real world when people are navigating the challenges that everyday challenges that we face. We look at the sort of study design. Basically, we do a sort of baseline assessment here as you can see, and then over time then our baseline assessment of cortisol. So again in this wall. This is the mass tasks is when we do the stress induction. So we're looking for the cortisol levels to increase. And then we basically then over the period of the study we then assess cortisol. So what we're looking for here is when we look at cortisol response. We're looking for this increase so this increase in cortisol being released at the time of the stressor. The hypothesis is that the people who have attempted suicide would release the least cortisol because their stress system isn't working as well as as the other groups. And that's exactly what we find. So here. Oh, Oh, the slides gone. So basically, what the slide was going to show was this lovely graph. Which has basically, we look at the cortisol response, the people who have attempted suicide release, release the least cortisol. So there's a blunt response, the people who've only thought about suicide, I've got a mid level amount of cortisol released, and then the people who have no suicidal history, they released the most. So that's what we're looking at instead for cortisol being important, being dysregulated and individuals who have attempted suicide. So then what we also did in that study was, in addition to understanding this difference between people attempted suicide, and people just thought about suicide. Well, actually, what might explain the obviously this flattened or this blunted cortisol response. And we look to childhood trauma, which again I mentioned at the very beginning of the talk, because we know childhood traumas associate a whole range of mental health problems. But bear in mind what the question we're asking here was the average age of our sample here is about the average age of the people come into our lab. The experiences they've experienced in childhood. So that could be anything up to the age of 16. What they tell us in terms of traumatic events that they experienced in childhood ago, those are predict how much cortisol they release in the lab today. And before I show that slide, just to illustrate how in people who attempt suicide and think about suicide, sadly trauma is so often part of the story part of the background. So all I want you to take from this, we look at the black bars, the black columns are individuals who the people have attempted suicide. And what they illustrate it doesn't matter which indicator of abuse that one uses. It's the suicide, the people who attempt suicide are much, much higher and indeed 80% reported at least some levels of childhood trauma. Now the next slide is this trying to then relate the amount of trauma people face to the release. It's what we're able to do is group our participants into those who'd experienced no trauma, those who'd experienced moderate levels, and those who'd experienced higher levels of trauma are exposed to it. And so this is like the figure you would have seen in the previous slide. That's disappeared. But what we've got here on this y-axis on the vertical axis are people's levels of cortisol. And this peak as you can see here, this is when we do the stress deduction and you can see it increasing. But what I want to just illustrate is draw your attention to this line. And this line here represents those individuals who have reported high levels of childhood exposure to trauma. And they're reporting the flattest response, the flattest response to cortisol after you control for all the standard things that you control. Okay, so that's the IMV for a second. So what I tried to do at the end of the second bit of the talk and in the last 10 minutes because we started a bit late, I'm going to move on to the COVID stuff that we've been doing. So the key message then, and this bit of the talk is that if we're trying to understand the transition from thinking about suicide to attempting suicide, we've got these volitional space factors, which are important. And we've also got these psychophysiological markers here. There's evidence that perhaps this dysregulation of the cortisol. In this study design, we can't determine cause and effect. And what we need to do is really do a longitudinal study, a real longitudinal study to look at how your cortisol levels change and how it relates to your suicidal history and deprivation and a range of other variables. Okay, so in the last bit of the talk, I wanted to want to just move on to COVID-19, given obviously it has affected all of our lives in ways that we could never have envisaged and seven months ago. And so seven months ago, and all from colleagues at the mental health research, Charlie called MQ Research. And basically, they were keen, they're the only dedicated mental health research charity in the UK. And they're really keen that we've tried to do something to really anticipate what the mental health consequences would be for people to really, for us to try and set priorities. So this paper then, so basically in conjunction with MQ, and then the Academy of Medical Sciences got involved, and then my colleague Emily Holmes and I together with Bill Moore, two psychiatrists. Basically, we all joined forces with this other group of people to put together these key priorities, mental health research priorities in the light of COVID-19. And in terms of centres priorities, one of the things we already had to do was monitor people's mental health, right? So what we're, and what we're going to present now is one of the things that I did, all right, let on, was trying to set up this cohort of individuals across the UK so we could monitor people's levels of anxiety, people's levels of thoughts, levels of entrapment and so on. And so very quickly, at the end of March, then I was able to convene and secure funding from some ardents Scottish Association of Mental Health and Mind Step, which is another charity, to put together and set up the UK COVID-19 mental health and well-being study. And as you can see, my collaborators quickly monitor people's in the representative sample, as far as we could do in that way, people's mental health and well-being over, over the, well, initially over the first six months of the pandemic. We've just finished, we have six data collections this week for how people see, assessing people's mental health. But what we focus in on the second is what we find in the first six weeks of lockdown. So this is the focus just from the period, but by the time we got ethics in place or ethical approval in place, we're able to go to the field to recruit our national sample starting on the sort of national UK sample, and then these data cover people's mental health and well-being up until, as you can see here, the 11th of May. So this is giving it, so representative of the UK population, so about 10% of samples in Scotland, and the study and then broadly representative, as you can see, outlined across the four nations of the United Kingdom. So what we focus in on this just really, this is our timeline for sort of policy related events pertinent to COVID. So I'm just focusing in when we're really in the midst of lockdown. For the 10th of May, there was some easing of restrictions, and obviously it was different for us in Scotland, but that's really this period here when we're really wearing the depth of lockdown. And we've got, I'm going to talk about three waves of data collection, as you can see here. And we've got really, really successful in recruiting people over or keeping people in the sample. And we also, in addition to this UK sample, the Scottish government have also funded us to recruit a second sample, a Scottish only sample, which is another two and a half thousand people. So, so these are just our broad characteristics of our samples. And I'm just focusing in on in our broad in our UK sample. So the questions, what will be fine so it's before I say what we find to only say that we can't say anything about people's mental health beforehand because we first came went to the field recruited our sample after lockdown. So what I'm interested in is people's trajectories in those six weeks, did their mental health get worse or better in those six weeks of lockdown. So what we find though is unsurprisingly and was reported by other some of the other studies internationally is, after a peak initially people's real we're all really anxious have no idea what was going to happen. You see this stark decrease in things that these are all just symptoms not diagnosis over the first three or six weeks, but you see a different pattern with the press of symptoms which are quite flat. So people's symptoms of depression were pretty stable over those first six weeks was a slight decrease, but not significant. So as we've been talking today about defeating entrapment also of interest you see this decreasing over time, still these these levels are all still really really high, at least double what you would expect in non COVID times. But you can see this decrease and defeat. So we looked at people's as people with their self harm and suicide attempts. Now these numbers are so small. So it's not we can't do any formal analysis, but what it's just worth noting is there seems to be potentially some evidence of increase in self harm and suicide attempts in those six weeks. So really important to highlight, especially in the context and really talk for the remainder of the presentation the last five minutes of presentation with suicidal thoughts. There's no evidence at all that suicide rates have gone up yet, although we are concerned, looking more longer term at the sort of consequences of the economic sort of security loss of jobs and so on. But what is dark and concerning is suicidal thoughts seem to be increasing. So although most people these are percentages. So thank you. Most people don't have them thought about suicide in the past week when we asked this question, but you see this increase is about 10% of people who are suffering from suicide by the sixth week six of the pandemic. So what's, but what's highlight here is, bearing in mind that levels of anxiety are decreasing depression is relatively stable. The people's suicidal thoughts seems to be increasing. We think that might be because that's tapping into the uncertainty and the fear in terms of jobs and opportunities and the future, which, which isn't taught by traditional measures of depression or depressive symptoms of anxiety. Just sort of just hone in them on some age groups. Again, this has been widely reported in the media. People's mental, there's four key groups who are much these mental health is more is worse or more badly affected. So we know that women has mental health is more badly affected men, young people's much worse, people from more socially deprived backgrounds is much worse. And those individuals with preexisting mental health problems much worse as well. And what we can see here is clear evidence of we look at these young people in green across the three ways their mental health of their suicidal thoughts are much higher, much higher than the other groups. Women, it's not statistically increased here are different, but women report marginal higher levels of suicidal thoughts across the pandemic or the early stages of lockdown. We look at socioeconomic status we see this very clear pattern again of those are more socially disadvantaged as is economic grouping, worse mental health in the context of suicide thinking. Existing mental health problems, exactly the same pattern, much much but the start the differences are stark here 20% versus 6% by way three comparing people with them about mental health problems. We also look at other groups. And this is looking at baseline wave one at the start of the pandemic. People who whose employment status had changed even at that early stage of the pandemic on surprisingly they were suicidal. Those individuals who had children under the age of five more suicidal and those who didn't. Those who told us that they weren't managing okay before the pandemic started in terms of finances, again, unsurprisingly, that their mental health in terms of suicidal ideation is similarly affected. Again, the start to start different there from 7% to 22 and a half percent. And you see the exact same pattern at the same exact same pattern at wave three. So it's just the same stable pattern of mental health impact of the lockdown. And then just a couple of slides and then I'll. This is really interesting one which is looking at people's access to outside space. And what's really of no tears unsurprisingly if you can access if you don't have access to outdoor space, your, your likelihood of suicidal thoughts is greater. But what's stark though is this increase. So it seems to get much worse over time. So again, as we'll be tracking this we haven't done the new analysis. Beyond me, but really interesting to see what happens out especially as lockdown has been eased, and then obviously it's been reintroduced over time. But again, another group of people who are particularly vulnerable. Loneliness as well, significantly higher levels of loneliness amongst young people, although they get slightly less lonely over time. But again, more markers of young people are spin have been the one group I would say that before the pandemic began that we probably didn't anticipate being as effective I certainly didn't anticipate at anticipated dealer groups, but I hadn't anticipated the strength of the effect on young people. So again, just your field of measures, same point with the press of symptoms, people who've got pre existing mental health problems unsurprisingly, if they've much more, much more or worse or more depressive symptoms across the first three ways. And then the fate and trapman just as it comes to the end here, the fate and trapman we see exactly same pattern. So people who have got a previous mental health condition they feel much more defeated, you feel much more trapped. Exactly the same. If you look at social grouping, people who are more socially lower social economic grouping, worse mental health in terms of fate, and in terms of entrapment, but again across the ways these are stable stable patterns. Okay, so come up to the end, just want to tie it all together with such a whirlwind of some conclusions. So what I tried to illustrate using lots of different sorts of research is that basically suicidal behavior is a complex phenomenon. Of course it is multi determined, multifactorial, but I think it's ultimately a psychological factor phenomenon, which is affected by all these range of various. And I just focused in on that second point there on the utility of a theoretical model like mine to gauge your research and crucially to differentiate, help us differentiate between people who just think about suicide and go a little further. And those who then make that transition from thinking to attempting suicide. But crucially the third bullet point though, is the reason this is important is because that's help us think about how we intervene, how we target individuals and groups as a societal level. So we can reduce the likelihood that people become suicidal in the first place to target the motivational phase, the middle bit of my model. But if you can't stop people being suicidal, you can also stop them hopefully making that transition from thinking to attempting suicide. So we talk about it as the intention, your suicidal intention to your suicidal behavior gap. What we're trying to do, we're trying to make that as wide as possible. So the few as few people as possible make that transition. And then the last bit I just try to give you some glimmer some insight into some of the recent work we've been doing, looking at the mental health and wellbeing of people in the pandemic but the concern in that with the pandemic is although there is no evidence yet. That suicide rates have increased, we have to be vigilant because there is signals like suicide reports data, which are suggesting that people can be vulnerable and are vulnerable. Okay, so that's me in a nutshell. So I'll end it there but just one last line which is what I hope I've done is try to challenge some of your views around why people become suicidal but crucially hopefully help you understand a bit more why sadly so many people think suicide for them, maybe the option and that we can all intervene and do our small bit to hopefully get those numbers down. Thank you. I have a couple of questions here about gun laws and whether Strix gun laws tend to reduce or whether countries such as the United States have higher prevalence. I wonder if that's something you could maybe comment on. Yeah, so in the United States, the leading cause of death by suicide is by handguns obviously but that's certainly not the case, that's not the case in the UK and actually you can statistically predict the suicide rates per month in each state of the United States from the number of guns owned in that state. So it's a clear issue, it's a big issue and I know colleagues working in the US are really trying to, because it's such a difficult one to tackle in the US because as we know it's kind of the size and so because the minute you try and restrict access, it becomes this big issue so what we try to do is increase the distance between an individual and their gun and that's the sort of suicide prevention efforts we're doing in the United States. But it's like the elephant in the room though because there's more people, more people by their own hand in the United States than are shot, meaning in terms of homicide. Okay, thank you. And possibly with a US theme still slightly. The question to greater levels of inequality in society leads to a greater likelihood of suicide attempts. Yep. Well, it's a huge issue. I mean, without a doubt, without a shadow without sweet, a few years ago we did the study even which looked at, it's an index of inequality obviously, which was not, we didn't ask people's absolute income. So the relative income, what they thought the relative income was was other people who lived in the same area across the UK. And the stronger predictor of suicide, suicidal behavior was the relative risk, the relative disadvantage. So the relative inequality rather than absolute inequality. So the first social disadvantage is, if we could sort of social disadvantage, we would go such such a distance to preventing suicide and it's actually absolute disgrace so we live in a country. So in most Western countries, we have this huge gradient this huge social class gradient, and that and indeed it is based on parts of the standard Glasgow. And you just mean the average age of people dying and a lot of that suicide is in your fifties, compared to obviously people who live in the Eastern Bartonshire or whatever maybe it's much higher, or they're obviously 70s. I mean, it's a huge issue which we need to do more about and make sure that, especially now in the pandemic that we're not going to make that inequality, even greater. Okay, and obviously people in prison, often there is an inequality, are prison rates of suicide higher than the general population. Sorry, sorry, Tony was asking whether suicide in prison is higher than the general population. So, um, so it's yes and no for that so in some studies show yes. Again, it depends. So they should. So I would say overall yes right but the issue is you have to then take into consideration is the people who are in prison, or bringing with them a whole host of risk factors anyway so preexisting mental health problems and so on. And we know that people on demand are incurred and at early stages of sentencing or increased risk. So they're higher at higher risk than other groups other prisoners. Okay. And several questions on courses old, which I mentioned. So for example, the effects of courses on the body depend not only on the circulating concentration in the blood, but also on the density of the courses or receptors. Do these differ between people of differing suicide risk. What a very specific question. I find here so I can under. So, where is that question is that that's a third from the bottom. No, not that one. Can't see that. Oh, the effects of course on the body depend not only on the circulating concert but also on density. I don't think we know enough actually about whether it's a it's a difference in receptors, or on on actually the where are the concentration in the body. So that's a good question. I don't think we know the answer to that question. So cortisol and suicide literature is really is a such a complicated literature fears that we published a meta analysis and so to complicate matters further results on age effects age moderates relationship. So actually, if you just say on average people under the age of 40, you see this positive relationship that actually people who attempt suicide have higher cortisol. So number 40 you see the reverse you see them, similar to what I talked about in the study you see the flattened response. And what we think is going on there is obviously the body is in the younger people, the body is just still responding to being repeatedly stressed but it's still working okay. And then obviously we're tying in the dysregulation hat. Even so that will complicate even further looking at the density issue, but great question. Leading us to fastening Rossman's asking, can the, can the courses of a curve from multiple stress events be modified. And if it can be modified. How do you do that. That's a great question as well. So the really interesting thing is so I didn't present these data but if we look at, if we look at the people who attempted suicide and we divided those into what we described as historical. And, and more recent so people actually tend to say more than a year ago versus those more recently. Most of that, most of the flattening is in that more recent group in the past 12 months. So that so we don't know. So, so we don't know what happened that what we described as a historical group did they get treatment or whatever. But their cortisol levels will aggregate the data their cortisol levels are have improved and they don't improve to the level of the control individuals, or even the ideas and closer to the ideation group. Now, but, but the answer to your other part of your question though is it to not in the suicide literature but there has been some work, which is looked at mindfulness can can does mindfulness and other stress reduction interventions does it alleviate or does it improve cortisol and there is some evidence that may do. So I think that we're just in this and really looking at this, especially an example like people with suicidal histories, but that's something we are actively looking at trying to develop some or trying to secure funding for some interventions based work to try and tackle that question. And then, for some, I guess also for medical background, do people taking corticosteroids for treatment of illnesses have a higher risk of suicide, and they're excluding those who develop steroids psychosis. I don't know directly the answer to that question but my, my, my hunch is that so it depends if you're taking the corticosteroids that for example people with chronic pain are increased risk of suicidal behaviors. So we'd have to, we'd have to try and disentangle that relationship from the medication relationship. So we do work on, we do work on pain, the physical pain tolerance I mentioned earlier. So we just, so we, so I, so we, so we don't know for certain will be my short answer. Okay. On the subject of pain median. What do you think about end of life suicide. Is it the same, or do you see it differently. I mean, I see it. I mean, in terms of my model of suicide, it's the same. I think the processes are the same, but the individual types lies in end of life. And as opposed to me, the, the tricky, well, it's just, it's such a difficult topic. Because if, so if we've lost, I come across so many people who, who were acutely suicidal and just for whatever, whoever's out there that are still alive after taking really medically serious suicide attempts, who at the time thought that they would that they were better off dead if they were so pleased they're alive. Right. So, it'd be careful that how, so in terms of end of life. It's just a tricky that's a issue. So my view is that I suppose I'm a member of the International Association for suicide prevention. So I would do whatever I can to help people. Hopefully not end their life, but I understood, I mean, it's a, it's a difficult issue and I suppose that's probably my way of responding to that question. Okay. From Pat, might chronic stress not be more important in affecting suicide risk than the acute stress that you simulated in the mast test. So chronic rather than acute. So I'm not, so I'm not making a more important out. So the point of the mass test is it's also trying in the laboratory, trying to disentangle effectively these relationships. So without a shadow of a doubt, I mean chronic stress, it mean is, is damaging, of course it is for me, that's, that's no surprise. But I think it was different for everybody. So, so some people, it's chronic stress, chronic stress, chronic stress. And then sadly, suicide attempt for others. It's people who, and there's an acute stressor, which leads to suicide attempt. So I don't think the same which is more or less important in that context. Stress in all its manifestations is part of the puzzle. But remember that's not the one, that's, there's never one explanation for suicide. In terms of what leads to stress, we've had a couple of questions here on perfectionism. And do you think that the adult experience perfectionism burdens and this and entrapment might be linked to early relational life experiences. Or do you think that perfection, perfectionism leads to greater internal entrapment. Okay, so there's two questions there. So the first, the development of perfectionism. So, perhaps, surprisingly, but there have been very few proper developmental longitudinal developmental studies looking at the emergence of perfectionism. I think Don suggests that, so invalidating experiences in childhood, inconsistent, inconsistent parenting experiences, trauma, the parents or caregivers as, as models of social perfectionism, all contribute to your own perfectionism. But like any other personality or individual differences factor, there are determining factors, and there's no inevitability. And remember, perfectionism in and of itself is not a bad thing. It only becomes like the good example of the diathesis stress relationship, it only becomes problematic, problematic in the presence of those. So, in terms of the relationship between perfectionism and entrapment, data to show that without a doubt. So I think the reason perfectionism, hopefully I'm saying I'm unstable, unstable, hopefully I'm okay. The perfectionism is perfectionism, social perfectionism in particular, which I mentioned increases your, I hypothesize increases your sensitivity to defeat and loss and so on. So we've got this situation in which, basically, I think of social perfectionism as having a psychological thin skin. And that's so, so when, when negative social things happens, loss, all those really things we all experience that somebody who's high in social perfectionism that's much more likely to get in. So that's much more likely then to start the pathway from defeat them to entrapment. So yes, is a short answer to your question. Thank you. And couple of questions here about interventions that one. Unfortunately, one of our audience lost two members of the family to suicide, and others attempted to others have had ideation and currently receiving support. So I'm terrified of it happening again. What support would you recommend. And related to that. Can you say something about nature interventions that can make an impact on the behavior gap. I'm just so where's that for that previous question because it's difficult to the fourth from the third from the bottom. Sorry, sorry, sorry, sorry. Okay, so I've lost two media fun members of suicide. I'm terrified of this happening again. I mean, that's a really, I mean, I really feel your anxiety and I saw him when he's lost. I under it is a real concern. I suppose it. Well, there's no easy, there's no easy, there's no one simple answer I suppose is what I'm trying to say except remember that that the vulnerability to suicide is there's all these multiple factors and that and it's really maybe keeping open if somebody has a pre-existing mental help or are they getting help and support they require. Are we keeping options open for them in terms of getting talking support and mean psychological support and so on. And obviously having this open relationship with your GP or whoever it may be, but I just think communications key. And remember that although statistic the statistical risk is high. And I know you what you've described obviously it's very close to home and is it, it's not inevitable. So hopefully that helps. Okay, thank you. Thank you for writing the factors. Do alcohol and drugs contributes from ideation to action. Yeah, so we, without a doubt, without a doubt. The reason they're not a lot of they're more generic issue one needs to deal with. So course we published the paper. Last year before, what we describe as alcohol, the list of alcohol related the list of factors effectively and they're looking at their cognition so definitely we know that alcohol. Obviously as a facilitator it's, but it increases your risk because it increases the likelihood that you're acting possibly it increases your risk because it makes you perhaps less fearful by dying and the same with drugs. The other thing with alcohol and drugs is anything which interferes with basic homeostatic. Interview with sleeping, for example, and relationships so sleeping I know relationships is not a homostatic function but sleeping is and sleep anything then which interferes with problem solving increases your likelihood. Just seeing some smart, smart comment there about the Michael Palin. Yes, I've had that several times. Last, last couple of questions there. Is there an experimental what is explanation if you know it for the sex difference in very kind of you broke up there so what's the explanation for the sex difference in suicidal sorts thoughts and suicidal incidents. Surprisingly, despite the fact of three quarters of all suicides by men and in every country in the world now men outnumber women. The gender differences are different. So there's, there's three to one gender difference in traditional Western countries, much much more closer to one on one in Asia. So the short answers we don't know for certain the part of it is as follows one is it may intend to use more lethal methods of suicide. And so sadly then the case fatality with the likelihood that method went and death is greater and then so I think it's probably the largest explanatory factor. And then there is things like help seeking is it men are less likely to seek help earlier and that is true that's not just a stereotypical myth. So some around that there's some around what masculinity and how he managed that and the challenges of, of being a man, the changing role of a modern society I think is, is difficult, whereas the female roles become better defined, which is fantastic. I think that the male role is not as well defined anymore. And the issue then about obviously reason now, for example, the biggest when I started in this field, the biggest risk group where people in their 20s men under 20s that was in the 1990s and I'm not risk group because I just got older obviously with the risk group. And now the largest risk group in the UK is middle age men. And that is also we So you think it may intend to have fear emotional supports in their life, right, which are so often it's invest in a partner. And then when those relationships break down for many in midlife. Because it's 50 x is almost 50% liable marriages in the UK and divorce of first marriages, and that that they're men are much more isolated and so emotionally disconnected so there's lots going on there but I think the largest one I think is those first two is methods method and not seeking help earlier, if I'm throwing a question way and you've mentioned Asia there. And I think at the beginning of your talk you talked about mental health being a factor in the Western world. Are there significant differences and does your model apply globally or do you think it is limited to the Western world. Well the model the model does apply. So again I deliberately do not have mental health problems in the model. Because I don't think the mental health problems part of the background you understand suicide risk. But so, so there's, and there's something. So I, without a shadow of a doubt. suicide usually happens in the context of mental health problems. However, if you look, if you look in Asia so it's so and some people estimate the upwards of 90% of all suicides. There's a mental health problem in the in the mix. If you look in Western Asian countries, it can be about 40 or 50%. And that and that is part of it. Some people argue that's just because perhaps the cultural differences that the mental health problems still still present but obviously it's not diagnosed I don't think it's that I think it's obviously because obviously psychiatric illnesses are the instructions of symptoms that we interpret and there's real pain, of course, but influences. So, so, so my model country because I think what's at the heart of it is entrapment that sense of being trapped. And I think what's at the heart of it is the sense of entrapment is different in different contexts. So we people have applied the model, for example, in India, in Africa, and, and obviously in other Western countries as well, for example and these still the common, these common factors that are the psychological processes I think are universal. Okay, and if I bring this close to the final question. And I think we should exclude lemmings from the answer to this. Are humans the only animals commit suicide, and if so, do you have any idea why. So, so we think that we are the only species with in their own life. And, and, but I think that's because the argument is you have to have whether three, obviously, some other primates can have three of mind, but I just so we've no evidence that chimps, for example, around and they would be are most likely, I think to see it and there's no way we've no evidence yet of the suicide convincing evidence, people have written papers saying all there's do, I just don't find any of this evidence convincing. So if you think about the key drivers is mental pain, right and feeling the burden and others and all these drivers. I just don't know that all other primates have that capacity might be wrong, but that will be my answer to it. Thank you very much. It's been a wonderful talk for you. You've been very patient with all these questions. I'm sure everyone have enjoyed it. I just wish you could hear the applause. No doubt is. It's just an unfortunate way that these zoom talks go but thank you very much for a very very stimulating very interesting lecture and is a pleasure hearing from you. Thank you very much. I really enjoyed it and hopefully people find it helpful. But just the last thing we go is really important self care is so so important. It's really difficult topic we've all been listening to tonight and so please if you are concerned about yourself for others, please reach out. It's asked if you're worried about somebody please ask them whether they're thinking of ending their life that does not plant the idea in their head it could get them the help that they require. And if you're worried about yourself please speak to your GP or some organs or other other organizations out there so please please look after yourself so so important.