Major Misconceptions About Suicide

“I just can’t take it anymore.”
I’ve heard countless patients make this confession in my clinic, quietly, shamefully, tears swelling in their eyes. I wonder if Ms. Kate Spade and Mr. Anthony Bourdain, in their final moments, alone in their apartment and hotel room, respectively, felt the same way.
My formerly homeless and incarcerated patients have shared myriads of stories, swallowed by their depths of despair, often manifesting as anger, frustration, mental illness and substance use. From successful lawyers and scientists to Marine Corps veterans to single mothers from South America.
The mystery and tragedy of suicide is shrouded by an almost cosmic connection between “us” and “them.” I did not know fashion mogul, Spade, but I can relate to being a woman with a highly stressful career; and as a daughter who loves her mother, I can barely fathom her 13-year-old’s emotional state. As a foodie with my own healthy spices website, I always felt that Bourdain had my job. Who wouldn’t want to travel the world, devouring delicious dishes? But like all of us, he had his demons including a debt-ridden career washing dishes as well as a history of drug addiction. And both icons experienced depression and anxiety.
Suicide is not a stranger in my family. Over 35 years ago, my mother’s cousin – Aunty Rita – killed herself in her early 30s, leaving behind two young children, her twin brother and devastated parents. While the details remain a mystery, we believe she lit herself on fire in her home in Bombay. Not a day goes by that her mother and my mother don’t fondly reminisce “Rita’s radiant smile” and irresistible laugh.

 

While an entire textbook can be written about suicide, I’d like to share five common misconceptions.

1. “People who take their lives are weak-willed.”As a society, we continue to stigmatize people with suicidal thoughts or who have died by suicide. Socially discrediting someone during their darkest moments deepens their feelings of hopelessness. Many, though not all, experience depression which is a “brain disorder, not a choice, and affects people without regard for looks, wealth or fame,” according to Candida Fink, a psychiatrist in Westchester, NY. The World Health Organization reports ~800,000 suicide deaths worldwide each year. Breaking down the taboo of suicide and mental illness is key in prevention and treatment.
2. “It mostly affects people who are really struggling – poor, unemployed, homeless.”Suicide does not discriminate. According to the Centers for Disease Control and Prevention (CDC), suicide rates have increased by 30% nationwide since 1999. While depression was a known diagnosis in ~50% of cases, many other factors play a role. Financial strain, health issues, and stress at home and work were all contributing factors. Suicide is the 10^th leading cause of death in the U.S. and one of only three on the rise (drug overdose and Alzheimer’s disease are the other two). Risk factors include prior suicide attempt, personal or family history of substance use or mental illness, chronic pain, family violence and guns at home.

• “Suicide affects everyone equally.” This is a bit of a trick. While suicide does impact people from all walks of life – across races, nationalities, religions, professions – some groups are disproportionately affected. Select at-risk groups (per CDC, NIMH):
• Men are more likely to die by suicide, but women are more likely to attempt suicide
• American Indians and Alaska Natives have the highest rate of suicide; non-Hispanic whites are 2^nd
• 6% of students in Grades 9-12 reported at least one suicide attempt in the past 12 months; girls attempted twice as often as boys (11.6% vs. 5.5%), highest among Hispanic girls (15%) vs non-Hispanic white girls (9.8%; per 2015 Youth Risk Behaviors Survey)
• 29% of lesbian, gay or bisexual youth attempted suicide at least once in the past year vs. 6% of heterosexual youth (CDC); suicide rates are highest among transgender individuals (41% vs 4.6% among the general public; per American Foundation for Suicide Prevention (AFSP)
• According to the Department of Veterans Affairs(VA), ~20 veterans die by suicide daily; 7,400 vets took their lives in 2014 (or 18% of all suicides in the U.S.). Suicide prevention, along with opioid safety, remain top concerns at the VA.
• Physicians have the highest suicide rate among any professional group, with ~400 doctors taking their lives annually in the U.S. In New York City, two doctors and a 4^th-year medical student died by suicide in the past five months
   
  3. “There’s nothing I can do to prevent a suicide.” – When a person takes his or her life, the people left behind often feel a sense of helplessness, even guilt. When my aunt died, my mother and other relatives felt they should have known; “we could have prevented her death.” As difficult as it might be to accept, no one else can be blamed for a loved one’s death by suicide. However, we can all take key steps. The National Institute of Mental Health (NIMH) recommends the following:
   
  • Ask: “Are you thinking about killing yourself?” Not easy, but studies show that asking does NOT increase the risk or suicide or suicidal thoughts.
  • Be present: Listen to your colleague or loved one. Observe their body language.
  • Safety: Minimize a suicidal individual’s access to lethal items (e.g. guns, knives, razor blades, stockpiled pills) or places (bridge, highway). Again, not always simple, but removing access to dangerous weapons/locations can be lifesaving. Of note, firearms are the most common method of suicide (with or without mental health issues; source: CDC), accounting for 51% of all suicides in 2016 (AFSP).
  • Connection: Stay in touch with someone after a crisis or recent hospital release. Suicide deaths decrease when we follow up.

4. 4. “I have nowhere to go.” The sense of hopelessness can be profoundly overwhelming. If you or a loved one needs help, please call the National Suicide Prevention Lifeline 1-800-273-TALK (8255) where trained counselors are available 24/7, seven days a week. Other numbers to save in your smartphone: a close friend or relative; the Crisis Text Line, 741741; and the local police department. National Alliance of Mental Illness (NAMI), Substance Abuse and Mental Health Services Administration (SAMHSA), NIMH and Zero Suicidealso offer excellent free online resources.

 

When I reflect on this past week, I am overcome with many emotions: sadness, confusion, loss. But I also remind myself to replace my biases patience, kindness and sincerity. I think we can all listen, without judgement, to our colleague who’s going through a divorce; our uncle who’s depressed about his wife’s dementia; our neighbor who wears a turban and smells “like curry.” Ask yourself, “What can I say or do to ease someone’s burden?” Our gestures needn’t be grand. Smile at fellow passengers on the subway. Hold a door open. Offer to carry a stranger’s grocery bag.
And if YOU are feeling helpless, alone and/or have thoughts of hurting yourself, please know that you are NOT ALONE. I promise you, someone will listen. Reach out to someone you know and trust, or to a trained professional. Your life has VALUE.
https://bit.ly/2sUXO1b

Colon cancer screening: Favor occult blood testing rather than invasive tests

Last week the American Cancer Society (ACS) released its updated guideline on colorectal cancer screening. The big news: the leading cancer society now recommends routine screening beginning at age 45 through the age of 75. Prior ACS guidelines from 2008, as well as other colorectal cancer screening recommendations, had recommended screening starting at age 50.

Notably, the downshift in the target age range for screening was not triggered by new clinical trial data supporting the change, but rather by modeling based on a rising prevalence of colorectal cancer among U.S. adults in their 40s. The new guidelines do indicate that screening in the 45-49 age bracket is a “qualified” recommendation, whereas screening for those 50 and above is a strong recommendation. However, the guidelines do not recommend counseling patients that there are a variety of expert opinions regarding when to initiate screening, and that beginning screening before age 50 has known risks but largely theoretical benefits.

In another change from the 2008 guidelines, the new recommendations now encourage clinicians to discuss multiple screening modalities with patients, including:

• fecal immunochemical test annually
• high‐sensitivity, guaiac‐based fecal occult blood test annually
• multi-target stool DNA test every 3 years
• colonoscopy every 10 years
• computed tomography colonography every 5 years
• flexible sigmoidoscopy every 5 years

Previous guidelines had favored invasive colon cancer screening strategies, such as colonoscopy, as the preferred approach. The American Gastroenterology Society similarly recommends colonoscopy as the preferred screening approach, whereas the United States Preventive Services Task Force recommends colon cancer screening with either “fecal occult blood testing, sigmoidoscopy, or colonoscopy” for adults ages 50 to 75.

The new recommendations provide us with an opportunity to review our Slow Medicine approach to colorectal cancer screening.

The Slow Medicine Approach

As we have previously written, we favor occult blood testing for colon cancer screening rather than invasive tests like colonoscopy (see also Rita Redberg’s great editorial making the case for this approach). Put simply, occult blood testing is the safest, simplest available screening strategy. According to a recent study published in Gastroenterology, unplanned hospitalizations occur following approximately 16 out of every 1,000 colonoscopies. Moreover, a 2013 Cochrane review found that sigmoidoscopy reduces the risk of colon cancer mortality from about 8 per 1,000 to 6 per 1,000 over 10 years (number needed to screen ~500).

Assuming that the benefits of sigmoidoscopy are comparable to those of colonoscopy, this means that you are about eight times more likely to end up in the hospital within a week of your screening colonoscopy than you are to be saved from colon cancer death over 10 years. Of the major screening guidelines, the only set constant with our approach is the 2016 Canadian guidelines, which recommend stool tests ever 2 years or sigmoidoscopy every 10 years.

As for the appropriate age to begin screening, we support the age bracket of 50 to 75 because this is the age group for which the data are most compelling. In fact, the Canadian guidelines highlight that the evidence for screening is strongest among those ages 60 to 74 and less so for those 50 to 60. Although we appreciate the rising incidence of colorectal cancer among younger individuals, we do not believe it would be justified to shift the screening age until rigorous evidence demonstrates the benefits of screening in younger populations; there are too many potential unintended consequences.

In summary, and at least until new data emerge, we believe occult blood testing should be the default method for colon cancer screening, with sigmoidoscopy and colonoscopy reserved for those who request it. Fecal tests are certainly the safest method. This strategy has the added benefit of providing more availability for colonoscopy among patients with a positive fecal occult test.

And until rigorous research demonstrates a clear and consistent benefit among younger populations, we think it is prudent to focus our screening efforts on those ages 50 to 75.

“Updates in Slow Medicine” applies the latest medical research to support a thoughtful approach to clinical care. It is produced by Pieter Cohen, MD, of Harvard Medical School, and Michael Hochman, MD, MPH, of the Keck School of Medicine at the University of Southern California. To learn more, visit the Updates in Slow Medicine website.

https://bit.ly/2MdEiG9

After pulling school shooting game, Steam will now ‘allow everything’

https://uw-media.usatoday.com/video/embed/35499597?sitelabel=reimagine&continuousplay=true&placement=uw-smallarticleattophtml5&keywords=video-games%2Csuffering%2Cstress%2Canger%2Coverall-negative&simpleTarget=&simpleExclusion=disasters&pagetype=story&cst=tech&ssts=tech%2Fnation-now&series=

Controversial video game “Active Shooter,” which allows players to assume the role of a school shooter, has been pulled from release.

(Photo: Getty Images/iStockphoto)

One week after yanking a game simulating school shootings off Steam, Valve Software said it will now takes a hands-off approach to what appears on its video game platform.

In a blog post published on Steam’s website, the company confirmed it will now “allow everything” on its service, with the exception of things they deem illegal or “straight up trolling.”

“Taking this approach allows us to focus less on trying to police what should be on Steam, and more on building those tools to give people control over what kinds of content they see,” reads an excerpt from the post.

Valve said it is working on giving players and developers more comprehensive tools to hide games of their choosing or to avoid harassment.

Last week, Valve removed a game called “Active Shooter” from the Steam marketplace following uproar over being able to allow players to simulate a school shooting. The game had been scheduled to launch on June 6.

In the game, described as a “dynamic SWAT simulator,” players could choose the role of SWAT team member attempting to diffuse an active shooter situation at a school, or control the shooter themselves.

Following an investigation, Valve learned a person identified as Ata Berdiyev was behind the game’s publisher, Revived Games, and developer Acid.

“Ata is a troll, with a history of customer abuse, publishing copyrighted material, and user review manipulation,” Valve spokesman Doug Lombardi said in a statement.

The game drew ire from parents of school shooting victims who said the game was inappropriate.

https://usat.ly/2xVNLih

Fed has a surprise in store that could mean an early end to interest rate hikes

• The Fed at its meeting this week is expected to announce a quarter-point interest rate hike, and a 0.2 percent increase in interest on excess reserves.
• The maneuver is targeted at holding back the target rate, and could signal that the Fed is nearing the end of its balance sheet rolloff.
• A preliminary end to the reduction in the bond portfolio also could signal a quicker end to the rate-hiking cycle than the market anticipates.

The Federal Reserve could have a surprise in store for investors this week, even if everyone already knows the central bank is raising interest rates.

Along with the quarter-point increase in the Fed’s benchmark short-term target, the policymaking Federal Open Market Committee is likely to announce another change that would signal an early exit from its history-making program to reduce the level of bonds being held on its balance sheet.

The mechanics are a little complicated. Yet it suggests that what once appeared to be an operation to shrink the amount of bonds the Fedowns — that would have run well into the next decade — could be wrapped up next year, or early 2020 at the latest.

Instead of reducing the balance sheet from its peak of $4.5 trillion to $2.5 trillion or so as some Fed officials indicated, the impact could be far less — perhaps, some suggest, to $3.5 trillion or even a little more.

It all depends on how tight financial markets get. Tightening in the money markets, and an unexpected push of the fed funds rate toward the high end of its target range, would be key factors in prompting the Fed to re-examine its policy normalization efforts from financial crisis extremes.

If the balance sheet runoff ends sooner then anticipated, investors probably can expect that the rate-hiking cycle could wrap up a bit earlier as well.

“There is a very active debate, and it’s probably really going to take hold at the August meeting, about how far the balance sheet contraction should really go,” said Fed expert Lou Crandall, chief economist at research service Wrightson ICAP.

“It’s easy to get breathless about this and say the Fed’s got a crisis. On the other hand, this is revealing that there are fewer truly surplus reserves in the system than we might have thought,” he added.

The predicament indeed seems far from a crisis. But the upcoming deliberations will give investors a window into how the Fed will unwind the stimulus it injected to help pull the economy out of the financial crisis, and ultimately how the market will react.

So far, the balance sheet reduction has proceeded with minimal market disruptions, but much work remains ahead of the central bank.

The mechanics

Here’s how it all works:

Since the financial crisis, the Fed had been a major player in the Treasurys market, snapping up nearly $2 trillion worth during three rounds of bond-buying that began in late 2008. Private demand has been left to pick up the slack since the Fed ended quantitative easing in 2016.

In October, the Fed began allowing a set amount of proceeds from its bond holdings to run off each month, while reinvesting the rest. Since that operation began, there has been a $102 billion reduction in Treasury debt and mortgage-backed securities on the balance sheet.

Concurrent with that has been a gain in interest rates, as the Fed also has raised its funds level; meanwhile, some upward pressure has built on government bond yields as the central bank has reduced its role in that part of the market.

Aaron P. Bernstein | Reuters

Federal Reserve Chairman Jerome Powell speaks at a news conference following the Federal Open Market Committee meetings in Washington, March 21, 2018.

Most recently, the funds rate has risen to near the top of the 1.5 percent to 1.75 percent target range the FOMC set after March’s hike. Specifically, the benchmark is at 1.7 percent, just 0.05 points away from the interest on excess reserves the Fed pays to banks that store cash at the central bank. The interest rate on excess reserves (IOER), as it is known, historically has served as a guide for the funds rate, and usually runs a bit above the Fed’s benchmark.

According to minutes from the May meeting, FOMC officials are concerned that the funds rate is rising a bit more quickly than anticipated, causing a tightening in money markets that would make a more aggressive unwind of the balance sheet problematic.

A solution suggested at the meeting was that the Fed raise the rate paid on reserves by 0.2 percent while it hikes the funds rate 0.25 percent. Doing so would be expected to hold back the funds rate from getting too close to the target ceiling, judging by the funds rate’s tendency to trail behind the IOER rate.

“We believe the Fed took this action since it has become increasingly concerned with the tightening in money markets over recent months and the pace by which its target fed funds effective rate is moving toward IOER,” Mark Cabana, rates strategist at Bank of America Merrill Lynch, said in a recent note to clients.

“While much of the money market tightening is due to U.S. fiscal policy (higher deficits and [Treasury] cash balance) we believe nascent signs of reserve scarcity are contributing to the move,” he added.

Cabana sees the balance sheet reduction concluding “toward the end of 2019 or in early 2020 at the latest, with risks for an earlier-than-expected end to the unwind depending on the Fed’s choice of monetary policy framework.”

Part of the calculus will be predicated on the amount of excess reserves running off.

Banks currently are holding nearly $1.9 trillion more than required at the Fed, a number that has fallen by about $300 billion during the balance sheet runoff. With regulations still demanding high cash levels for the nation’s biggest banks, Crandall estimated that level of reserves won’t dip much below $1.5 trillion.

That’s a little more conservative than Cabana’s projection that banks won’t want to see excess reserves, which peaked at $2.2 trillion, depleted by more than $1 trillion total.

In balance sheet terms, Crandall’s estimate implies a level of about $3.7 trillion — or half a trillion below current levels, he said. By October, the Fed will be allowing $50 billion a month to roll off, meaning that the balance sheet reduction could be finished by later summer or early fall 2019.

Closing the roll-off program earlier than expected would be consistent with a growing sense at the Fed that it is nearing the end of this rate-hiking cycle. The policymaking FOMC has hiked the benchmark rate six times starting in December 2015, and is indicating two more hikes this year and three the next.

However, with inflation remaining muted, some members believe the funds rate won’t need to go much farther.

The balance sheet rundown will be done “by the middle of next year,” Crandall said. “That’s optimistic on my part, but I don’t think that’s unrealistic.”

https://cnb.cx/2xVXLIs

Kase Learning Short Selling Conference Presentations 2018

Whitney Tilson recently launched a new investment conference focused on short selling called the Kase Learning Short Selling Conference.  They’ve released some videos of pitches from the presentations and we’ve aggregated them here along with notes from each talk if you just want a quick summary.

Click each link below to go to the presentation.

Kase Learning Short Selling Conference Presentations 2018

– Sahm Adrangi (Kerrisdale Capital): On ad fraud and Quinstreet (QNST)

– Mark Spiegel (Stanphyl Capital): Short Tesla (TSLA)

– Gabriel Grego (Quintessential Capital): Short Folli Follie 

– Jillian McIntyre (221B Capital): Short Intelsat (I)

– Berna Barshay (Viola Capital): Short Ralph Lauren (RL)

– Enrique Abeyta: Short Anheuser Busch InBev (BUD) 

– Chris Brown (Aristides Capital): Short Energous (WATT)

– Asher Jacobs & Jade Hu (Columbia MBAs): Short Stericycle (SRCL)

https://bit.ly/2McVmvS

Visualizing how US household finances are changing

VISUALIZING SHIFTS IN INCOME, SAVINGS, DEBT, AND SPENDING

Courtesy of: Visual Capitalist

FROM PEAK TO PEAK

In 2007, real median household income had a local peak of $58,149, and then fell off a cliff at the same time as the credit cycle, which reached its own peak in 2008 Q3 as the financial crisis set in.

Real median household income bottomed in 2012, and then debt followed in 2013.

Looking at the most recent year of data available, both categories are now back above pre-crisis highs. Real median household income has now surpassed its all-time record in 1999 – and total household debt has topped $13 trillion in 2018 Q1, more than $500 billion higher than its previous peak in 2008.

A CLOSER LOOK

While consumer debt is similar in terms of total size from a decade ago, the composition has changed considerably.

Mortgage debt, which makes up the vast majority of consumer debt, is still actually down from its 2008 peak by 4%. Replacing that is other forms of debt, including student loans:

Note: it appears the data listed in this table is one quarter more recent than Meeker’s, which was represented in chart

Since 2008, student loan debt has surged by 131% – and auto loans by 52%. Mortgage debt, credit debt, and other non-housing debt have not yet crawled back to pre-crisis peaks.

SAVING AND SPENDING

Looking at the longer-term trend, Americans are borrowing more and saving fewer dollars.

In the 1970s, both rates were about the same as a percentage of income, falling in a range between 13-15%. Today, the savings rate is below 5%, and debt-to-annual income ratio has risen to 22%, according to Meeker.

What are American households spending money on?

Notably, households are spending more on shelter and healthcare – meanwhile, the cost for food, entertainment, and apparel are decreasing over time.

https://bit.ly/2JsAzqz

GE grows FlexFactory presence in China with another cell therapy plant deal

GE Healthcare has announced plans to install its second FlexFactory manufacturing platform for cell therapy, this time at Xiangxue Pharmaceuticals site in Guangzhou, China.

Xiangxue Pharmaceutical (XPH) has selected GE Healthcares FlexFactory a semi-automated manufacturing platform to advance clinical and commercial production of cell therapies.

The project marks the first FlexFactory installation for the manufacture of cell immunotherapy drugs based on high-affinity and high-specificity T cell receptors.

A GE spokesperson told us the companies have signed the agreement and are discussing next steps for installation.

The FlexFactory platform is expected to be operational in March 2019,” the spokesperson said.

Rapid speed China

According to GEs general manager of cell and gene therapy Ger Brophy, a combination of innovation, regulation, and manufacturing is taking place at a rapid speed in China.

XPH is an example of a company in China that is already preparing for future commercialization by collaborating with GE Healthcare to scale up their manufacturing processes, he told us.

The XPH deal follows Shanghai-based Cellular Biomedicine Groups (CBMG) adoption of the FlexFactory platform the first ever for the application of cell therapies announced in January this year.

Later that month, GE continued to grow its FlexFactory presence in China, with the announcement that Clover Biopharmaceuticals would adopt the platform at its facility in Zhejiang, to make a biosimilar version of Amgens Enbrel.

https://bit.ly/2MdppUk