University Times

David Brent (left) is congratulated by Provost James Maher

Paraphrasing a lesson from the Talmud, a prominent Pitt professor and clinician said he learned much from his teachers, more from his students, but most of all from his patients — “especially the patients I was not able to help. If everybody fits your theory, it may make you feel good, but it doesn’t push the field forward.”

David A. Brent was installed Nov. 25 by Provost James Maher as the inaugural endowed chair in suicide studies, the first such endowed chair in the United States. “Today we’re celebrating the inspiration of Professor David Brent, whose research is on suicide and its behavior and prevention in children and adolescents,” Maher said before a packed house at Frick Fine Arts auditorium.

“It’s both regrettable and understandable that this chair stands alone,” Brent said in an emotion-packed Provost’s lecture titled “The Risk of Doing Nothing.” “Suicide is a topic very easy to avoid, because the act of suicide goes against the thing we hold most dear: the preciousness of life. For the University and the medical center to recognize suicide studies is really an affirmation of life.”

Brent, who was named professor of psychiatry in 1994 and who holds appointments as professor of pediatrics and professor of epidemiology, boasts an outstanding research record, Maher said, including 96 peer-reviewed articles, 47 of which list Brent as the sole or first author, and more than 40 book chapters. Brent also has been honored recently with awards from his alma mater, Jefferson Medical College, as well as the American Psychiatric Society and the Suicide Prevention Society, among other professional organizations, Maher noted.

According to Brent, suicide is the 11th leading cause of death world-wide, claiming 1 million victims annually, and the third leading cause among young people, who are Brent’s focus.

“I remember back in 1979, when I was working at Children’s Hospital evaluating kids to see which ones should be sent to Western Psych,” Brent said. “And a father asked me, ‘You’re sending my daughter there, but not this other child: What exactly is the difference?’ I made up something about confidentiality, but it really made me realize how bereft our field was that I couldn’t give him an answer. I went to the library, and was struck with how little was available. We had no knowledge of the cause of suicide, or the risk factors, or even ways to assess risk, no empirical evidence.

“Did I make a huge mistake going into child psychiatry? I asked myself. The field was such a mess.”

Instead Brent drew motivation from the death of his brother, who, in their final conversation, left Brent with a thought that drives him today. “He was a musician, a composer. And I remember asking him, “Who are you listening to these days?’ and he said, ‘Me.’ I told him that was very egotistical. ‘Don’t you think you can learn more from listening to somebody else?’

“He replied: ‘I’m listening to the music I’m going to write.’ I took inspiration from him. I wanted in my own field to hear the music not done yet,” Brent said choking back tears.

By 1980, Brent said, adolescent suicide rates had tripled compared to 1960, but there were still no clear treatments for depression or suicidal behavior. The common view was that an adolescent suicide victim had been “misunderstood” or “was under too much stress,” and parents almost always shouldered the blame.

But even with the increase in teen-age suicide, there are only 10-20 victims per every 100,000 adolescents. “How do you study 100,000 kids to get at those 10 or 20 who may be suicidal? I began looking at comparing people who attempted suicide with those who completed suicide,” to learn the difference, Brent said. “But the problem with suicide, of course, is the victims took those answers with them.”

So Brent set out to learn everything he could from the families of suicide victims. “Everything I do is very low-tech: I began by talking with the friends and families of victims,” Brent said. “At first I was very frightened to make that first contact, but the difficulty turned out to be not gaining entree to those families, but leaving those families.”

In addition to sharing the survivors’ pain, Brent said he felt a strange sense of exhilaration, because “I realized that many of these suicides could have been prevented. When you began to understand what the factors were that went into these suicides, there actually was something concrete that could be done.”

From those interviews came important findings that informed his research agenda during the past two decades, including:

• 90 percent of suicide victims suffer from psychiatric illness for an average of seven years before they commit suicide, “so there is a long lead-time to combat this,” he said.

• Families who ascribed victims’ mood disorders as “normal ups and downs of adolescence” themselves showed a high rate of mood disorders. “[These reactions] were coming from families loaded with mood disorders, so to them it was normal behavior,” Brent pointed out. But mood fluctuations in teen-agers that lead to socially dysfunctional impairment need to be treated as a disease, he said, and public education on teen mood disorders is warranted.
• There is a high degree of preparation behavior prior to suicide attempts, so suicide intent is a high-risk factor for suicide, and behavior can be a useful indicator.
• Contrary to the myth that those who talk about suicide do not follow through, suicidal thoughts and attempts, and suicide completions, are linked. “Always take threats and attempts seriously,” Brent advised.

• Suicide victims often tell a friend sworn to confidence of their intentions. Brent said the wish to live co-exists with the wish to die, or else why would someone wanting to kill him- or herself tell anyone who could influence that decision? “So we have to educate friends to tell an adult and let the adult take the consequences of violating a confidence,” Brent said.

He added that friends who honor such confidences often are devastated by guilt for years. “The impact is not only on the individual, the impact of suicide affects the whole network of people,” Brent said.

• About one-third of suicide victims had distinct plans to harm someone else within a week of a suicide attempt, which suggests a link between suicide and aggression, Brent said.
• Genetic factors should be considered, Brent said, because a large percentage of suicide victims are from families with high rates of mood disorders, substance abuse, depression and suicide attempts themselves.
• Guns are common in homes of at-risk teen victims, so reducing the availability of guns could reduce the number of suicides.
• Depression is a common factor in suicidal behavior, so treating depression should have some impact on lowering suicide rates.

In more recent years, Brent said, cognitive therapy, which focuses on how distorted thinking patterns can provoke ill-chosen actions, has made inroads in treating depression.

Indicators of depression include feelings of hopelessness; impulsive behavior and poor problem-solving skills, which can lead to dichotomous thinking such as “Should I live or die?”

In a 1997 clinical trial, Brent and colleagues showed that cognitive therapy can help depressed patients substitute more adaptive behaviors for their either/or thinking. “Cognitive therapy was better than other treatments for reducing depression, but still only 60 percent of patients are responsive, and there was no differential effect on suicidal thoughts,” Brent said.

This leads to the paradox that treating depression may be necessary, but also may not always be sufficient in preventing suicide, he said.

“The majority of patients with mental disorders do not attempt or complete suicide,” Brent said. What does seem to be prevalent in patients with mental disorders who attempt or complete suicide is aggressive behavior, he said.

Brent is pursuing studies of genetic links as suicide indicators, as well as behavioral patterns, especially aggression, among relatives of suicide victims and attempters.

“But these studies make everybody nervous, including funding agencies and IRBs (institutional review boards), because they require the use of high-risk subjects,” Brent pointed out.

Such studies raise ethical issues. For example, is it ethical to use a high-risk subject in a drug trial when the subject might not care if a drug does harm?

“Secondly, IRBs focus more on risk and not on potential benefits. But what of the ethical issue of doing nothing?” Brent asked.

“Depression is potentially fatal, and suicide complicates that. There is a risk, for the individual, of doing nothing.”

—Peter Hart