FOUNDATION CHILD 10th European Research Training Seminar ...€¦ · David Shaffer, F.R.C.P., F.R.C.Psych. Source Research Funding Advisor/ Consultant Employee Speakers’ Bureau

June 24, 2013 9:00–9:45 A.M.

Monastero Santa Croce Bocca di Magra, Italy

David Shaffer, F.R.C.P., F.R.C.Psych. WITH: Regina Miranda, Ph.D.; Michelle Gallagher, M.A.; Ana Ortin, Ph.D.

Columbia University/New York State Psychiatric Institute 1051 Riverside Drive, New York, NY 10032

UNMET RESEARCH AND CLINICAL NEEDS

1) The Meaningful Measurement of Suicide and Risk for Suicide

2) The Unmet Needs of Older Teenagers and Young Adults with Anxiety Disorders

06/24/2013

FOUNDATION CHILD

10th European Research Training Seminar in Child and Adolescent Psychiatry

“Planning for the Future: Research and Evidence-Based Practice”

Columbia University New York State

Psychiatric Institute

PRESENTER’S DISCLOSURES OF POTENTIAL CONFLICTS

David Shaffer, F.R.C.P., F.R.C.Psych.

Source

Research

Funding

Advisor/

Consultant Employee

Speakers’ Bureau

Books,

Intellectual

Property

In-Kind

Services

(e.g., Travel)

Stock

or Equity

> $10,000

Honorarium or

Expenses for

This Presentation

or Meeting

Foundation

Child — — — — — — — YES

AFSP — YES — — — — — —

APA — YES — — — — — —

Carmel Hill

Foundation YES — — — — — — —

Sallie

Foundation YES — — — — — — —



[CT24]

© 2013 Shaffer

[#1662]



ACKNOWLEDGEMENTS

Debbie Ann Chambers

Mark Davies, M.P.H.

Prudence Fisher, Ph.D.

Madelyn Gould, Ph.D., M.P.H.

Angela Kaon

Lillian Polanco, M.A.

Michelle Scott, Ph.D.



BACKGROUND



SUICIDAL IDEATION

STRESSOR e.g. Trouble with Law/School Loss Frustration

Humiliation

• FIND & TREAT

MO3

ACUTE MOOD CHANGE

e.g. Anxiety/Dread

Hopelessness

Anger

• HOTLINE

ACTIVE DISORDER e.g. Mood Disorder

Substance Abuse Alcohol Abuse

(Pessimism)

COGNITIVE SET

SURVIVAL SUICIDE

HOW SUICIDES OCCUR AND HOW THEY CAN BE PREVENTED (1)

— P A T H S T O I D E A T I O N —

• STRESS AVOIDANCE

AND TOLERANCE (DBT)

© 2013 Shaffer

#0370



FACILITATION

SOCIAL

Religiosity

Available Support

Access to Method

Consider Effect on Others • MEDIA GUIDELINES

MO4

• METHOD CONTROL

SURVIVAL

Slowed Down

MENTAL STATE METHOD AVAILABILITY/ COMPETENCE

UNDERLYING “IMPULSIVE” TRAIT

Recent Example Weak Taboo Being Alone

SOCIAL

INHIBITION

MENTAL STATE Agitation

• HOTLINE

• FIND & TREAT

HOW SUICIDES OCCUR AND HOW THEY CAN BE PREVENTED (2)

— P A T H S F R O M I D E A T I O N —

• ALCOHOL RESTRICTION IMPACT OF ALCOHOL

• EVENTUAL BIOSCREENING

© 2013 Shaffer

[#0371]

SUICIDE OR ATTEMPT

SUICIDAL

IDEATION



“SUICIDALITY”

IDEATORS

NON-SUICIDAL SELF-INJURERS

LOW-RISK ATTEMPTERS

HIGH-RISK ATTEMPTERS

SUICIDES

[E] © 2013 Shaffer

#2385



0

5

10

15

20

25

30

35

40

45

50

55

60

65

0–4

5–9

10–

14

15–

19

20–

24

25–

34

35–

44

45–

54

55–

64

65–

74

75–

84

85+

White Males

White Females

Black Males

Black Females

Age E5

Ra

te p

er

10

0,0

00

CDC, NCIPC 2005 (WISQARS) (cited 11/30/2012)

2010 SUICIDE RATES BY GENDER & WHITE/BLACK RACE

— U N I T E D S T A T E S, A L L A G E S, 2010 —

#2370

© 2013 Shaffer



0

2

4

6

8

10

12

14

16

18

20

22

24

26

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Males

Females

Ra

te p

er

10

0,0

00

Age [E70/SI]

2010 YOUTH SUICIDE RATES BY GENDER

— U N I T E D S T A T E S, A G E S 10–24, 2010 —

CDC, NCIPC 2005 (WISQARS) (cited 11/30/2012) © 2013 Shaffer

#2371



SA12 Hawton et al. 2000

SUICIDE ATTEMPTS (DSH) ACROSS THE LIFECYCLE

— B Y S E X, 2000 —

#0271



SOME REASONS FOR FAILURE TO MEET OBJECTIVE TO DIE

Ambivalent intention

Change of intention (Aborted)

Inadequate planning

Inadequate mastery of method

Chance interruption (Interrupted) © 2013 Shaffer

#NEW [SA]



? REASONS FOR DECLINE IN TEEN ATTEMPTS WITH AGE

SA11

Environment: Reduced conflict as

behavioral boundaries are settled.

Development: 1)Better coping ability for

common stressors 2)More-effective

behavioral inhibition 3) Reduced

egocentricity & greater awareness of

consequences for others

© 2013 Shaffer

#0270



RISK FACTORS

Psychiatric Disorder



LOCATION N YEARS %

Israel 43 mid-1980s 90%

*New York 120 1984–1986 90%

Finland 53 1987–1988 94%

*Pittsburgh 140 1984–1994 82%

PSYCHIATRIC DISORDER IN ADOLESCENT SUICIDE

— P S Y C H O L O G I C A L - A U T O P S Y S T U D I E S —

D17 Apter 1993, Shaffer 1996, Marttunen 1991, Brent 1999; *case-control studies #0598



MALE FEMALE

(N=213) (N=46)

Depression 50% 69%

Antisocial 43% 24%

Substance Abuse 38% 17%

18- to 19-year olds* 60–67% 13%

Anxiety 19% 48%

66% of 17- to 19-Year-Old Male Suicides Have Substance/Alcohol Abuse

MOST COMMON DIAGNOSES IN TEEN SUICIDES

Brent et al. 1999, Shaffer et al. 1996; *N=120 D18 #0599



DIAGNOSTIC PREDICTORS OF SUICIDE ATTEMPTS

Great Smoky Mountains Study

NON-SUICIDAL SUICIDALITY RAW N=6570 N=101 OR

†p ≤ 0.05; Foley et al. 2006 D34 #0615

Pure Depression 0.59 3.01 11.61†

Pure ODD 1.31 5.77 8.27†

Pure CD 1.36 3.90 6.63†

Pure Anxiety 1.85 0.50 0.58

Depression + GAD 0.10 20.43 468.53†

Depression + ODD 0.11 10.61 222.94†

Dep + Anx + Disruptive 0.15 3.84 52.68†

Dep + Disruptive + Alc Abuse 0.07 0.52 16.45†



THE PROBLEM

Attempts Usually Assumed to Be the Best Indicator

of Later Suicide



Ideation* 13.8% (2.97 million)

Attempt* 6.3% (1.49 million)

Attempt involving 1.9% (409,000)

medical attention*

SUICIDE (ages 15–19)** .0075% 1,669

*CDC MMWR (YRBS) 2010; **CDC, NCIPC 2005 (WISQARS) (cited 12/12/2012) [E46/SI]

FREQUENCY OF SUICIDAL IDEATION AND BEHAVIOR

— U. S. H I G H - S C H O O L S T U D E N T S —

(N=16,410, 12-Month Incidence, 2009)

RATE TEENS 15–19

© 2013 Shaffer

#2278



MANY ATTEMPTS, FEW SUICIDES

— U N I T E D S T A T E S , A G E S 15–19 , 2009 —

Rates/100,000

DEATHS* ATTEMPTS** RATIO

Males 11.63 4,600 1:396

Females 3.18 8,100 1:2,547

*CDC, NCIPC 2005 (WISQARS) (cited 12/12/2012); **CDC MMWR (YRBS) 2010 E38 © 2013 Shaffer

#2277



RISK OF SUICIDE IN U.S. AFTER ATTEMPT

FEMALES – n.s.

MALES 10%

[E] © 2013 Shaffer

#NEW



MOST-COMMON OUTCOME MEASURED IN SUICIDE TREATMENT STUDIES

Repeat suicide attempts

BUT

Only significant predictor for males

Not representative of all attempters

[PT/SI30] © 2013 Shaffer

[#0154]



“SUICIDALITY”

IDEATORS

NON-SUICIDAL SELF-INJURERS

LOW-RISK ATTEMPTERS

HIGH-RISK ATTEMPTERS

SUICIDES

[E] © 2013 Shaffer

#2385



VALUE OF STUDYING SUICIDE IDEATION

1. High prevalence might make it a better outcome measure than behavior in treatment studies

2. As a window into psychopathology (and treatment) of suicide

3. As a predictor of suicide?

[PT/SI]

© 2013 Shaffer

#2095



MOOD, ANXIETY, AND SUBSTANCE-USE DISORDER IN UNREFFERED

CURRENT TEEN IDEATORS

MECA (N=641)

Any Ideation 48.5%

No Ideation 18.5%

OR 4.2 (2.7–6.5)

SI128

© 2013 Shaffer

#0252 Gould et al. 1998 (MECA)



Most are theory driven

Approaches to validation mostly

clinic vs. unreferred

Most assume enduring states and

ignore fluctuation with mood context

None based on empirical findings

PROBLEMS WITH IDEATION SCALES

© 2013 Shaffer

[#2037] [PT/SI]



MEASURING IDEATION

Ascertainment



ENDORSEMENT OF SUICIDALITY AND METHOD OF ASSESSMENT

(Descending Order of Prevalence)

�

Face-to-face interview

Self-completer form with identifiers

Computer-administered questionnaire

SI79 © 2013 Shaffer

#0203 see Greist et al. 1973



ASCERTAINMENT TECHNIQUES

Inventories, e.g., SIQ, SIS

Structured interviews

Performance tasks, e.g., IAT

© 2013 Shaffer

#2031 [SI]



SELF-COMPLETION VS. DIRECT INTERVIEW

(Yigletu 2004; N = 68 Adult Inpatients)

�

20% said “yes” in self-completion

and “no” in face-to-face

Agreement higher with age and

education

[SI] © 2013 Shaffer

#2432 Yigletu 2004



RECALL OF IDEATION

Adelaide Longitudinal Study (GHQ)

40% of 19-year-old ideators

would deny lifetime ideation

when asked at age 23

Goldney et al. 1991 [SI] #2096



PARENTS’ KNOWLEDGE OF ADOLESCENT IDEATION

Montreal Longitudinal Study (N=1,715; community)

F M

Child Report 13.7% 4.8%

Parent Report 6.7% 3.0%

IDEATION IN LAST 6 MONTHS

Brezo et al. 2007 © 2013 Shaffer

#2030 [SI]



PREDICTING ATTEMPTS FROM QUESTION QUALIFIERS

(Shaffer et al 2002)

1. Do you still think about …

2. Do you often think about …

3. Do you think about … seriously

4. Do you think about … for a long time

[SI/SA] © 2013 Shaffer

#2101



IDEATION MEASURES



INTENT

2003 ACISR Grant

I have no desire to kill myself

I have a weak desire to kill myself

I have a moderate to strong desire to kill myself

I do not expect to make a suicide attempt

I am unsure that I shall make . . .

I do not have the courage or the ability to commit suicide

I have the courage or the ability to commit suicide


[#2100]



SUICIDE SEVERITY RATING SCALE

Beck al. 2004

MODAL/DOMINANT

Interval frequency

Duration of thoughts

Controllability/Intrusiveness (can you stop thinking about killing yourself or wanting to die if you want to?)

Level of intent (how much do you want to be dead/how certain are you that you want to die?)

Deterrents

MOST SEVERE

AS ABOVE

NOW

How likely is it that you will attempt suicide in the future?

SI76 [#0200]



PASSIVE IDEATION

Beck Scale for SI 0 I would try to save my life if I found myself

in a life-threatening situation

1 I would take a chance on life or death if I

found myself in a life-threatening situation

2 I would not take the steps necessary to

avoid death if I found myself in a life-

threatening situation

Intercept Scale 0 I would take precautions to save life

1 I would leave life/death to chance

2 I would avoid steps necessary to save or

maintain life

SI6 © 2013 Shaffer

#0133



MORBID THOUGHTS

Rumination about people who have died

Preoccupation with dead bodies, working for an undertaker/taxidermist, etc.


#2335



REASONS FOR LIVING (BECK)

2003 ACISR Grant

Beck Scale for SI

0 I would not kill myself because of my family, friends, religion, possible injury from an unsuccessful attempt, etc.

1 I am somewhat concerned about killing myself because of my family . . .

2 I am not or only a little concerned about killing myself because of my family . . .

Beck Scale for SI

0 My reasons for living outweigh my reasons for dying

1 My reasons for living or dying are about equal

2 My reasons for dying outweigh my reasons for living


#2035



MOTIVATION TO COMMIT SUICIDE (REYNOLDS SIQ)

2003 ACISR Grant

Reynolds SIQ (29) I thought if things did not get better I would kill myself

Reynolds SIQ (30) I wished that I had the right to kill myself

Reynolds SIQ I that killing myself would solve my problems

Reynolds SIQ I thought that others would be better off if I were dead

Reynolds SIQ I that people would be happier if I were not around

Reynolds SIQ I thought no one cared if I lived or died


#2036



EXCEPTIONS



PREDICTORS OF DEATH OR

SSI* (current) 5.42

SSI (worst) 13.84

BHS** 6.43

PAST ATTEMPTS (BECK)

(3,701 Adult OPs, 30 Suicides; Follow-Up=2 Weeks–12 Years)

Beck et al. 1999; *Scale for Suicide Ideation; **Beck Hopelessness Scale SI60 [#0184]



CIRCUMSTANCES OF PRIOR EVENT

— C I R C U M S T A N C E S O F A T T E M P T S I S S U B S C A L E S —

ISOLATION

1. Isolation

2. Timing

3. Precautions [active/passive] against discovery/intervention

PLANNING

4. Final acts in anticipation of death (e.g., will, gifts, insurance)

5. Active preparation for attempt

6. Suicide note

7. Overt communication of intent before the attempt

Beck et al. 1974 SI58 #0182



USEFUL ASCERTAINMENT

�

Focus on Contingencies

What did you do?

When did you decide?

Where were you?

Who was with you?

Why, what happened before then?


#2388



CONTINGENT STATUS/CONTEXT

(CDRS, Poznanski)

CDRS Has thoughts of

suicide, or of hurting

himself/herself,

usually when angry


[#0139]



TRYING SOMETHING NEW



Pre-attempt ideation is, by definition, “predictive”

[PT]

LOGIC of NEW RESEARCH

[#2285]

© 2013 Shaffer



Try to get a count from open ended questions? e.g.

Number of days in last week?

Number of thoughts in a day?

Number of hours spent ruminating?

Amount of interference with other activities?

INITIAL CONSIDERATIONS Rejected


#0233



Can ideation be deconstructed & quantified (frequency, duration, sequence ) e.g.

Interval between event and stressor/trigger etc?

Pattern

Duration of components

Associated Mood

[PT]

GOALS

[#2285]

© 2013 Shaffer



VALIDITY Proximity to event (

i.e. PRE ATTEMPT)

RECALL 1)Interview within 5 hours, 2) orientation reminders in

time sequenced segments.

[SA]

METHOD APPROACH

#SHAFFER 2013



[PT/SA]

SCOPE OF ENQUIRY

#2142

WAKES UP THE EVENT Post-Event Status

W E



INITIAL ANCHOR: Event that led to admission

– Location (drawing)

– Time

– Other people nearby

2ND ANCHOR: Waking up that morning

– Sequencing

– Video metaphor

ASSISTING RECALL (after open ended enquiry )

[SA] #2140



LOCATION OF ATTEMPT

LIVING ROOM

BEDROOM

BATHROOM

[PT/SA] #2287

© 2013 Shaffer



ELABORATING RECALL OF EVENT

– – Physical consequences, pain, etc.

– Interpersonal consequences

SHAFFER 2013



SEQUENCE

EVENT 1 (STRESSOR)

EVENT 2 (TRIGGER)

EVENT 3 (ACTION TAKEN)

W E

T S

[PT/SA] [#2143]

© 2013 Shaffer



An event that induces a change in

mood, but without suicidal thoughts;

the mood is terminated by ideation

or might cease spontaneously

EVENT 1 (STRESSOR)

[PT/SA] #2288

© 2013 Shaffer



An event followed by the

onset of suicidal ideation

EVENT 2 (TRIGGER)

[PT/SA] #2289

© 2013 Shaffer



PRELIMINAR RESULTS

1. Pilot study (2007) N=42

2. Current study (2012) N=64



RECRUITED: 106 adolescents (ages 12–19)

Teens presented to pediatric ER or clinic with a recent suicide attempt or recent ideation

– 6 individuals excluded because method of attempt involved cutting

– 1 person excluded because attempt occurred a year prior to referral

– 2 individuals ended the interview early

FINAL SAMPLE: 97 (57 ideators, 40 attempters)

[PT]

RECRUITMENT

#NEW PATIS 2013



[PT]

SAMPLE CHARACTERISTICS

#NEW

TOTAL

(N=97)

IDEATORS

(N=57)

ATTEMPTERS*

(N=40)

Mean Age (SD) 15.15 (1.9) 15.25 (2.4) 15.05 (1.8)

Female 77% 75.4% 80.0%

Ethnicity

Hispanic 72% 74% 71%

White 12% 12% 12%

Black 10% 11% 10%

Other 6% 3% 7%

PATIS 2013; *attempter group excludes 5 individuals whose suicide attempt method involved cutting and 1 individual whose attempt occurred 1 year prior to referral

© 2013 Shaffer



26 by overdose

– 14 took 20 or fewer pills – 1 ingested cleaning powder and pills

8 by penetrating injury – 7 cut – 1 puncture

3 by suffocation/asphyxiation

2 by jumping from a height

1 by walking in front of a car

0 with firearms

[PT]

ATTEMPT METHODS USED

#NEW PATIS 2013



STRESSORS &TRIGGERS

STRESSOR: An event that induces mood change, e.g.

irritability, anger, and remorse

TRIGGER

An event that indces suicidal thoughts

SI136

© 2013 Shaffer

[#0260] PATIS 2013



[PT]

STRESSOR EVENTS

#NEW

ATTEMPTERS (N=12)

Stressor Present 11 of 12

Type of Stressor Interpersonal Event 9

Dispute 7 of 9 Person Involved*

Parent 4

Peer/Sibling 1

Other Adult 1

Boyfriend/Girlfriend 2

Other Negative Event (e.g., failing exam)

2

PATIS 2003; *one individual had a dispute that involved both a parent and a sibling



#9: Finds out sister has stolen gift she had bought for her mom and gave it to her on Mother’s Day

#19: Expected a phone call from her boyfriend, but the boyfriend failed to call her

#30: Told not allowed to attend her graduation ceremony because of unreturned school book

#31: Told she could not go out on a planned shopping expedition with her cousin

FRUSTRATIONS

[PT/SA] #2292

© 2013 Shaffer



: EARLY FINDINGS (IN GIRLS)

1. 3–12 hours prior to ingestion, an unexpected, frustrating event

2. Stressor induces mood change, with irritability, anger, and remorse

3. 10–30 minutes before ingestion, overhears rejecting remark induces suicidal thoughts

© 2013 Shaffer

[#2039] [PT/SI/SA]



[PT]

TRIGGER EVENTS

#NEW

ATTEMPTERS (N=12)

Trigger Present* 10 of 11

Type of Trigger Interpersonal Event 7

Dispute 6 of 7 Person Involved**

Parent 5

Peer/Sibling 0

Other Adult 0

Boyfriend/Girlfriend 2

Other 2

Saw the Method 1 PATIS 2003; *all individuals without a triggering event experienced some form of negative cognition (e.g., self-criticism, hopelessness) prior to the start of ideation; **one individual had a dispute that involved both a parent and a boyfriend/girlfriend



Predominantly interaction with parent or boy/girl friend;

might involve overhearing and not an interaction

[SA]

TRIGGER EVENTS

#NEW



[PT]

STRESSOR-TRIGGER INTERVAL

#NEW

ATTEMPTERS (N=20)

≤ 1 Hour 3

1–3 Hours 10

3–6 Hours 5

6–12 Hours 1

13–24 Hours 1

In most cases, the trigger event occurred within 6 hours of the stressor event

© 2013 Shaffer PATIS 2013



TIME INTERVAL BETWEEN TRIGGER AND ATTEMPT

(Total Attempters, N=40)

9

8

5 5

8

5

0

1

2

3

4

5

6

7

8

9

10

Immediately Within 1–10Minutes

Within 11–30Minutes

Within 30Minutes–I Hour

> 1 Hour Unable to Rate

#NEW [PT]

13%

23%

20%

13% 13%

20%




The initiation of the attempt usually occurred within

30 minutes of the decision to make an attempt

[PT]

INTERVAL BETWEEN TRIGGER & ATTEMPT INITIATION

#NEW

TIME AFTER DECISION ATTEMPTERS (N=28)

Immediately 10

1–10 Minutes 9

11–30 Minutes 3

> 30 Minutes 6




[PT]

DURATION OF IDEATION

#NEW

ATTEMPTERS

(N=36)

≤ 1 Hour 12

1–4 Hours 7

5–12 Hours 8

12–24 Hours 1

> 24 Hours 7

Still ideating 1




[PT]

CONTENT OF IDEATION

#NEW

ATTEMPTERS (N=40)

Process of dying (e.g., pain,

fall asleep) 20 (50%)

What would happen after

death (e.g., funeral, heaven) 18 (45%)

Effect of death on others 26 (65%)

ATTEMPTERS (N=12)

Ideation contained images 8 (67%)

PATIS 2013



EMOTIONS EXPERIENCED AFTER THE TRIGGER

EMOTION ATTEMPTERS (N=12)

Sadness 89% (8 of 9)

Anger 100% (12 of 12)

Anxiety 43% (3 of 7)

Relief 0% (0 of 7)

Guilt/Shame 57% (4 of 7)

Confusion 71% (5 of 7)

Loneliness 67% (4 of 6)

[PT/SA] #2293

© 2013 Shaffer



[PT]

EMOTIONS EXPERIENCED AFTER ONSET OF IDEATION

#NEW

EMOTION ATTEMPTERS (N=12)

Sadness 70% (7 of 10)

Anger 100% (10 of 10)

Anxiety 78% (7 of 9)

Relief 29% (2 of 7)

Guilt/Shame 43% (3 of 7)

Confusion 71% (5 of 7)

Loneliness 67% (4 of 6)

PATIS 2003



CONCLUSIONS

Psychological Mechanisms and Clinical Value



COMPETING MODELS OF SUICIDAL THOUGHTS

1. Self-directed aggression

2. Hopelessness/futility

3. Impulsiveness

4. Joiner’s rehearsal theory

5. Escape theory with cognitive “deconstruction”

6. None of the above

SI130

© 2013 Shaffer

[#0254]



JOINER’S THEORY OF MENTAL REHEARSAL Joiner & Rudd 2000; Joiner et al. 2000

Ideation allows habituation to fear

of pain and injury

WOULD BE SUPPORTED BY

1. Reduced relationship to provocation

2. Increased severity of method

Conclusions not yet examined 3 Shaffer2013



COGNITIVE SENSITIZATION

i.e., provocative experience that

leads to greater accessibility

and sensitivity to triggers

Fits observations

[#2040] [SI/SA]



BAUMEISTER: “ESCAPE” AND THE PSYCHOLOGY OF SUICIDE

“Escaping an aversive situation

and obtaining respite from a

terrible state of mind”?

see Baumeister 1990 [#2077] [SI/SA]



ESCAPE THEORY

Baechler 1975; Baumeister 1990 [SI/SA74]

Current circumstances are below expectations

Self-blame

Comparison with others

NEGATIVE MOOD

(“Cognitive deconstruction”)

Attempt to dissociate

Goal and actions are focused

Disinhibition

SUICIDE ATTEMPT

#0333



CONCLUSION

Fits Observations

An interesting approach to

deconstructing to anxiety?

#NEW [SI/SA]



IMPLICATIONS

Exploration of stressor is valuable

for selecting both sensitivity to

provocation and excessive

responsiveness (both important

targets for intervention)

Brief interval between trigger and

attempt behavior makes method

control crucial

[PT] #NEW

Documents

FOUNDATION CHILD 10th European Research Training Seminar ...€¦ · David Shaffer, F.R.C.P., F.R.C.Psych. Source Research Funding Advisor/ Consultant Employee Speakers’ Bureau