Beth Howard, Special to Association of American Medical Colleges, News December 17, 2019
Teaching hospitals are taking bold new approaches to reduce suicide rates, including rapid identification of at-risk patients and aggressive follow-up care.
Diana Cortez of Tacoma, WA, was in her 20s when she first thought of taking her own life. “I thought I was losing my mind,” she says. “I didn’t understand what was going on, how those thoughts could just come into my mind.”
Cortez began taking an antidepressant, but thoughts of killing herself became obsessive until one day, she took a lethal dose of her diabetes medication. She was rushed to the hospital, where she was treated and sent home with a higher dose of the antidepressant.
Cortez would attempt suicide four more times. But the last time, in 2010, was different. Her family took her to Harborview Medical Center at the University of Washington in Seattle. “The doctor looked at me and said, ‘I’m sorry you’re going through this. I just want to tell you that I’ve had patients who’ve been where you’re at right now and they’re not only living, but having a life worth living,’” she remembers.
Cortez started a year-long treatment program in dialectical behavioral therapy (DBT), a type of psychotherapy that has been shown to reduce suicide, and doctors followed her progress closely. Now 54, Cortez is rarely disturbed by thoughts of suicide, but she has a safety plan in place if they crop up. “I told my sister that I’d text her the word ‘help’ if I was in trouble,” she says. “That alone, the fact that I told her about it, and that we made a plan, helps. Because as soon as somebody else is involved, that snaps me right out of it.”
“Suicide prevention requires a comprehensive approach, with multiple sectors involved, and that makes it more challenging than other issues where there might be a single intervention that can have a dramatic outcome.” — Richard McKeon, PhD, Substance Abuse and Mental Health Services Administration
Cortez is one of the lucky ones. Deaths from suicide have risen 30% over the last 12 years in the United States, for reasons that no one fully understands, says Richard McKeon, PhD, chief of the suicide prevention branch at the Substance Abuse and Mental Health Services Administration, part of the Department of Health and Human Services. Although no complete count of suicide attempts is available, the 2017 National Survey on Drug Use and Health found that 1.4 million adults ages 18 or older tried to take their own life that year. Easy access to firearms, rising rates of mental illness and substance abuse, and socioeconomic inequality are believed to be key culprits.
But success stories like Cortez’s are becoming more familiar as hospitals and health systems rethink their approach to suicide prevention. More are adopting evidence-based treatments and working suicide intervention into care beyond behavioral and mental health departments — strategies endorsed by the U.S. Surgeon General in the National Strategy for Suicide Prevention, released in 2012. More recently the Joint Commission has required hospitals and behavioral health centers to follow new rules around suicide prevention, including screening patients for risk and improving follow-up after at-risk patients are discharged.
“Suicide prevention requires a comprehensive approach, with multiple sectors involved, and that makes it more challenging than other issues where there might be a single intervention that can have a dramatic outcome,” says McKeon.
The new ideas, many of which were pioneered in the mid-2000s by the Henry Ford Health System, have been bundled into an approach called Zero Suicide, which has been adopted by approximately 1,000 hospitals and health systems around the country, says Julie Goldstein Grumet, PhD, director of Health and Behavioral Health Initiatives at the Suicide Prevention Resource Center. (SPRC has developed a free, online toolkit of best practices for health systems interested in implementing Zero Suicide.)
Here are some of the things hospitals are doing to tackle the rising suicide rate:
Evidence suggests that people should be asked directly about any thoughts of suicide. And health systems that are committed to reducing suicide should ask everyone, including those who present in the emergency department or at primary care appointments, not just those who are receiving mental health care. In fact, between 70% and 75% of suicides occur in patients not receiving mental health treatment, McKeon says.
“The idea is that if we have this person in front of us for a checkup, a mammogram, a colonoscopy, a cold, or the flu, they’re here and we can do something about helping them to not kill themselves,” says Barbara Stanley, PhD, professor of medical psychology at Columbia University Vagelos College of Physicians and Surgeons and director of the Suicide Prevention — Training, Implementation and Evaluation program at the New York State Psychiatric Institute’s Center for Practice Innovations.
“We used to think that if you treated the primary disorder, like bipolar disorder or depression, that suicidality would just go away. We no longer think that. Patients need that kind of treatment, but they also need to address the specific risk factors that lead to suicidality.” — Barbara Stanley, PhD, Columbia University Vagelos College of Physicians and Surgeons
Health systems are coming up with effective tools to make screening for suicide risk a routine part of care. Kaiser Permanente relies on questionnaires and structured assessments as well as data from electronic health records (EHRs). “They allow us to identify people at risk for suicide attempts as well if not better than a Framingham Score for heart disease,” says Gregory E. Simon, MD, MPH, a psychiatrist and senior investigator at the Kaiser Permanente Washington Health Research Institute. People who screen positive for suicide risk then get a more in-depth risk assessment.
Limiting access to firearms and other means of suicide has always been a strategy for reducing suicide, but hospitals are now getting more aggressive about it. At the Henry Ford Health System, which reduced its rate of suicide by 80% when it started prioritizing suicide prevention, clinicians sit with each at-risk patient and his or her family and ask them specifically how they imagined or even planned to take their own life, then had the family take action. If a patient mentions a gun under the bed, the family is tasked with removing it.
“Then we would confirm that they had done a sweep of the house and had indeed secured that weapon,” says C. Edward Coffey, MD, vice president and former chair of psychiatry at Henry Ford and now affiliate professor of psychiatry and behavioral sciences at the Medical University of South Carolina College of Medicine in Charleston. “And we would have this conversation at every subsequent encounter with the patient.”
Health systems that have moved the needle on suicide have found that the right treatment is crucial. “We used to think that if you treated the primary disorder, like bipolar disorder or depression, that suicidality would just go away,” says Stanley. “We no longer think that. Patients need that kind of treatment, but they also need to address the specific risk factors that lead to suicidality.”
Numerous treatments have been shown to reduce suicidal behavior, including cognitive behavior therapy and DBT specifically addressing suicide, which Cortez received. “Usually these have focused on people who have already made a suicide attempt and on trying to reduce repeat suicidal behavior,” McKeon says.
Even when treatment is progressing, patients need tools to avoid suicide during a crisis. “People used to be asked to sign a no-suicide contract, which says something like ‘I won’t kill myself,’” McKeon says. “But there has never been any evidence for its effectiveness and there is actually evidence that it could be harmful in some situations.”
Now patients are urged to create an individualized safety plan to help divert their attention from the impulse to kill themselves. “Often it’s either a matter of minutes or hours before somebody goes from thinking about suicide to actually trying it,” says Stanley, who co-developed the Safety Plan Intervention used by the Department of Veterans Affairs with Gregory K. Brown, PhD, at the Perelman School of Medicine of the University of Pennsylvania. “We try to identify with patients what warning signs they experience and what activities they can do by themselves to take their mind off of it.”
For instance, a patient’s safety plan might include playing a video game, playing with their pets, or calling a friend or therapist. “This is not about solving all of your life’s problems,” Stanley says. “This is about getting you through this crisis without you killing yourself, so that you can then go on to solve those problems.”
Research shows that the most vulnerable time for patients at risk for acting on their suicidal thoughts is in the first 30 days after discharge from inpatient care or ED. And the first day or two post-discharge is particularly risky.
Yet “typically we send them home from the ED with a piece of paper, maybe with referrals on it,” says Stanley. “We’re relying on them, somebody who is in a crisis, to make the appointment and get to the care.”
But aggressive follow-up and after care can make a huge difference. In a study of 1,200 patients at five Veterans Affairs hospitals around the country, Stanley showed that when patients created individual safety plans and hospital staff called them several times — the first within 72 hours of discharge — suicidal behaviors were reduced by 50% and more patients started outpatient treatment.
“Suicide has historically been understood as the unfortunate but inevitable outcome in some patients with mental illness and the Zero Suicide conviction challenges this assumption.” — M. Justin Coffey, MD, Geisinger Health
Centerstone, a behavioral health care system based in Tennessee, which lowered its suicide rate by 62% in the first two years of adopting Zero Suicide tactics, is relentless about patient follow-up. After a family has discussed means reduction with a clinician, they get a call within a day to make sure that guns and potentially lethal substances have been removed from the patient’s household.
When patients don’t show up for therapy sessions, the EHR has been programmed to relay the patient’s name to the crisis call center and a high-risk follow-up team. “That says to those guys, ‘This is someone on a suicide pathway, go find them,’” says Becky Stoll, vice president for Centerstone’s Crisis and Disaster Management. “The majority of the time people just forgot or they meant to cancel. But we’ve had a good number of active rescues that way. One guy was standing on the Natchez Trace Parkway Bridge about to leap to his death when he received a call from us, 20 minutes after his appointment time.” The patient was talked down and taken to a medical facility.
The EHR at Centerstone and at other institutions is used to flag at-risk patients, spot trends, and measure the results of interventions — a critical part of the process to continually improve.
Centerstone also created a suicide prevention app for patients that allows them to track their moods and sleep and reminds them to take their medications. Data is shared with clinicians to help monitor at-risk patients.
Proponents point out that significantly lowering suicide rates takes more than adopting a set of practical measures. It requires a mind shift and a passionate commitment to change.
“Suicide has historically been understood as the unfortunate but inevitable outcome in some patients with mental illness and the Zero Suicide conviction challenges this assumption,” says M. Justin Coffey, MD, chair of Geisinger’s Department of Psychiatry, Addiction Medicine and Behavioral Health, who heads suicide prevention there and also collaborated with his father, C. Edward Coffey, at Henry Ford. Says the elder Coffey, “Zero Suicide requires a radical conviction that we can achieve ideal health care.”
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