The Sophie Fund recently organized a small conference with a big purpose: to introduce and implement the Zero Suicide Model in Tompkins County. Together with Ithaca’s Suicide Prevention & Crisis Service and the New York State Suicide Prevention Office, we invited the most senior healthcare leaders from local government, medical centers, and college campuses to attend an expert briefing on October 16 at The Statler Hotel.
Healthcare leaders from Ithaca and Tompkins County
The presenters were two of the nation’s leading authorities on suicide prevention:
—Michael Hogan, a developer of the Zero Suicide Model, who served as New York State Mental Health Commissioner (2007–2012), Ohio Department of Mental Health Director (1991–2007) and Connecticut Mental Health Commissioner (1987–1991).
—Sigrid Pechenik, Associate Director of the New York State Suicide Prevention Office.
Turnout for the briefing was excellent. Attendees included: Tompkins County Public Health Director Frank Kruppa, who also serves as the county’s Mental Health Commissioner; Deputy Mental Health Commissioner Sharon MacDougall; senior administrators from Cayuga Medical Center and Family & Children’s Service of Ithaca; and health directors from Cornell University, Ithaca College, and Tompkins Cortland Community College.
Suicide is absolutely not an inevitable outcome for people struggling with suicide ideation related to mental illness or other factors. The Suicide Prevention Resource Center argues that “we all have a role to play” in preventing suicide.
The American Foundation for Suicide Prevention explains that “suicide most often occurs when stressors exceed current coping abilities of someone suffering from a mental health condition”—and part of the problem is that conditions like depression often go undiagnosed or untreated.
AFSP outlines the risk factors and warning signs for suicide, and the critical steps that suicidal individuals and their families and friends can take when such factors and signs are present. Risk factors include mental health conditions, stressful life events, and a family history of suicide. Warning signs include talking about pain and suicide, increased alcohol or drug use, withdrawing from family and friends, and exhibiting anxiety or loss of interest.
The Zero Suicide Model, sometimes called the “Suicide Safer Care Model,” goes further. Zero Suicide argues that suicides can be prevented by closing cracks in healthcare systems—that “suicide deaths for individuals under care within health and behavioral health systems are preventable.”
As Hogan and Pechenik emphasized in their Statler presentations, Zero Suicide means making suicide prevention a core responsibility of healthcare. Specifically, this entails a systematic clinical approach in healthcare systems—training staff, screening for suicide ideation, utilizing evidence-based interventions, mandating continuous quality improvement, treating suicidality as a presenting problem—and not simply relying on the heroic efforts of crisis staff and individual clinicians.
Sigrid Pechenik, Associate Director, New York State Suicide Prevention Office, and Michael Hogan, former New York State Mental Health Commissioner
As SPRC puts it: “The programmatic approach of Zero Suicide is based on the realization that suicidal individuals often fall through multiple cracks in a fragmented and sometimes distracted healthcare system, and on the premise that a systematic approach to quality improvement is necessary.”
Certainly, the facts make a compelling case that healthcare settings must play a critical role in preventing suicide. According to Pechenik, a review of New York State data of 3,564 suicides in 2013–2014 identified that 25 percent of the individuals who took their own lives had been discharged from emergency departments or inpatient facilities within just seven days prior to their suicide deaths.
The data also indicates a strong need to better train clinicians in suicide screening, assessment, intervention, and follow-up. Of 1,585 mental health providers surveyed by the NYS Office of Mental Health in 2014, 64 percent reported little or no specialized training in suicide-specific interventions. Moreover, about 33 percent reported that they did not feel they had sufficient training to assist suicidal patients.
Zero Suicide is at the heart of the 2012 National Strategy for Suicide Prevention, released by the U.S. Surgeon General and the National Action Alliance for Suicide Prevention. The NSSP’s Goal 8 is to “promote suicide prevention as a core component of healthcare services.” Goal 9 is to “promote and implement effective clinical and professional practices for assessing and treating those at risk for suicidal behaviors.”
As Pechenik noted, Zero Suicide is also explicitly embraced by the NYS Suicide Prevention Plan 2016–17, entitled 1,700 Too Many. Implementing Zero Suicide in health and behavioral healthcare settings is the first pillar of the suicide prevention strategy outlined in the plan. The second pillar is to “create and strengthen suicide safer communities.”
According to the U.S. Substance Abuse and Mental Health Services Administration, “There is strong evidence that a comprehensive public health approach is effective in reducing suicide rates.”
Hogan pointed out that the Zero Suicide Model builds on breakthroughs such as the Perfect Depression Care Initiative implemented in 2001 by the Henry Ford Health System in Michigan. Its comprehensive approach to mental and behavioral healthcare—incorporating suicide prevention as an explicit goal—demonstrated a 75 percent reduction in the suicide rate among Henry Ford health plan members.
More recently, Hogan highlighted, The Joint Commission issued a Sentinel Event Alert on the imperative of improving suicide prevention in healthcare settings. The Alert is important because the commission is a body that accredits and certifies nearly 21,000 healthcare organizations and programs (including Cayuga Medical Center) across the country—such accreditation and certification is a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
The Joint Commission’s February 24, 2016 Sentinel Event Alert Issue 56, entitled “Detecting and Treating Suicide Ideation in All Settings,” stated:
“The Joint Commission urges all healthcare organizations to develop clinical environment readiness by identifying, developing and integrating comprehensive behavioral health, primary care and community resources to assure continuity of care for individuals at risk for suicide.”
The Sentinel Event Alert recommended detailed actions for suicide ideation detection; the screening, risk assessment, safety, treatment, discharge, and follow-up care of at-risk individuals; educating all staff about suicide risk; keeping health care environments safe for individuals at risk for suicide; and documenting their care.
The commission’s focus on suicide prevention in healthcare settings stems from the belief that while being alert to risk factors and warning signs is important, it is not sufficient. There is no typical suicide victim: most people with risk factors don’t attempt suicide, and others without risk factors do. Thus, the Alert stated:
“It’s imperative for healthcare providers in all settings to better detect suicide ideation in patients, and to take appropriate steps for their safety and/or refer these patients to an appropriate provider for screening, risk assessment, and treatment.”
The Alert reported that many communities and healthcare organizations presently do not have adequate suicide prevention resources, leading to the low detection and treatment rate of those at risk. It noted that although most people who die by suicide receive healthcare services in the year prior to their deaths, healthcare providers often do not detect their suicidal thoughts. “Supportive continuity of care for those identified as at risk for suicide is crucial,” the Alert said.
The Joint Commission reported that in 2014 many commission-accredited organizations were actually rated non-compliant with its National Patient Safety Goal 15.01.01 Element of Performance 1: “Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide.”
The commission said its database recorded 1,089 suicides occurring from 2010 to 2014 among patients receiving care, treatment, and services in a staffed, around-the clock care setting or within 72 hours of discharge, including from a hospital’s emergency department. According to the Alert, “The most common root cause documented during this time period was shortcomings in assessment, most commonly psychiatric assessment.”
The Joint Commission said its Sentinel Event Alert aimed “to assist all healthcare organizations providing both inpatient and outpatient care to better identify and treat individuals with suicide ideation.” The Alert listed areas for improvement:
—Clinicians in emergency, primary, and behavioral healthcare settings particularly have a crucial role in detecting suicide ideation and assuring appropriate evaluation.
—Behavioral health professionals play an additional important role in providing evidence-based treatment and follow-up care.
—For all clinicians working with patients with suicide ideation, care transitions are very important. Many patients at risk for suicide do not receive outpatient behavioral treatment in a timely fashion following discharge from emergency departments and inpatient psychiatric settings.
The Sentinel Event Alert noted that suicide is the 10th leading cause of death in the United States, taking “more lives than traffic accidents and more than twice as many as homicides.” In 2011, according to data published by the U.S. Centers for Disease Control, suicide became the second leading cause of death for Americans aged 15-24.
In April 2016, the National Center for Health Statistics reported a 24 percent increase in the suicide rate in the United States from 1999 to 2014. While age-adjusted death rates for heart disease and cancer have dramatically declined in the last two decades thanks to improved detection and treatment strategies, the suicide rate has skyrocketed.
On September 15, 2017, the U.S. National Institute of Mental Health reported that three interventions, which were designed for follow-up of patients identified with suicide risk in hospital emergency departments, save lives and are even more cost effective than usual care. The interventions were sending postcards to patients at risk; calling discharged patients to offer support and encourage follow-up treatment; and connecting patients to suicide-focused cognitive behavioral therapy programs.
“In the face of a gradually rising suicide rate, the need for effective prevention strategies is urgent,” said NIMH Director Joshua Gordon. “These findings of cost-effectiveness add to the impetus for implementing these life-saving approaches. Importantly, they also make a strong case for expanding screening, which would allow us to reaching many more of those at risk with life-saving interventions.”
It is the hope of The Sophie Fund that the October 16 briefing at The Statler Hotel is the start of a process of garnering commitments from local healthcare leaders to develop implementation plans that bring the Zero Suicide Model to Tompkins County.
To achieve ultimate success, “buy-ins” will be needed from major healthcare systems including psychiatric units, emergency departments, and college health centers, as well as from primary care providers and substance use disorder treatment centers.
To assist healthcare organizations in implementing the seven fundamentals of Zero Suicide, SPRC established the Zero Suicide project offering online resources such as an organizational self-study, implementation toolkits, readings, and webinars, and an offline Zero Suicide Academy providing two-day trainings for healthcare leadership.
The NYS Office of Mental Health operates the New York Academy for Suicide Safer Care, which offers a 9-12 month program of webinars and coaching calls for organizations seeking to raise their standard of suicide care.
The Statler briefing follows several encouraging local developments in suicide prevention during 2017.
On April 17, community mental health stakeholders representing 18 organizations adopted The Watershed Declaration, calling suicide a “serious public health concern” and pledging to intensify suicide prevention efforts in Ithaca and Tompkins County.
On June 7, 2017, Ithaca Mayor Svante Myrick issued a proclamation supporting The Watershed Declaration and calling for “an all-out effort to prevent suicide.” The Tompkins County Legislature issued a similar proclamation on September 5, 2017.
On July 31, led by the Tompkins County Department of Mental Health, local mental health leaders launched the Tompkins County Suicide Prevention Coalition representing 32 organizations including health, behavioral health and substance use disorder treatment facilities, schools, and county departments.
—By Scott MacLeod and Susan Hack
Scott MacLeod and Susan Hack are officers of The Sophie Fund, Inc., a nonprofit charitable corporation supporting mental health initiatives aiding young people in greater Ithaca and Tompkins County.