Zero Suicide: Safe Care in all Healthcare Settings

Michael Hogan, former New York State Commissioner of Mental Health and co-developer of the Zero Suicide Model, asks healthcare professionals to reconsider a conventional wisdom.

How much should we rely on upstream suicide prevention efforts like reducing suicide causes and risk factors such as trauma, mental illness, addiction, economic insecurity, pain, loss, and isolation?

Speaking at the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30, Hogan agreed that upstream strategies are important and worthy of pursuit.

Yet, he warned in his presentation, “If Preventing Suicide is our Target, Suicide Safe Care—in all Healthcare Settings—Is the Bullseye,” upstream strategies are nonetheless “woefully inadequate and unlikely to affect rates of death in the next several decades.”

“It’s unreasonable to expect rates of suicide to decrease because of upstream prevention activities unless we really, really dramatically increase them,” Hogan explained. “We have inadequate access to care, as a very significant number of people with mental health problems don’t get care. The great majority of people with addiction problems don’t have access to care. Reducing suicide by curing depression is a very tough call. Big factors like economic insecurity or human pain and loss and isolation are very tough things to fix in our society.”

Part 2 in a Series about the Zero Suicide Model for Healthcare

Hogan noted that the success in preventing cardiovascular disease by reducing smoking through upstream activities included 30 surgeon general reports, national and state education campaigns, anti-smoking laws, and significant taxes on tobacco products—and still required a 50-year effort that remains unfinished.

Hogan argued that the suicide prevention field can learn from other medical fields that have achieved decreasing rates of death, from heart disease and cancer, for example, due to preventive interventions. He likened the potential of utilizing the Zero Suicide Model for those at risk of suicide to the success of preventive interventions and treatments such as statins, stents, and valve replacements for those at risk with cardiovascular disease.

As heart disease deaths have been reduced through targeted preventive interventions for people at elevated risk, Hogan said, suicide risk can be mitigated by identifying and managing suicidality through targeted preventive interventions such as screening, safety planning, reduction of lethal means, and caring contacts.

“Just as we can identify high blood pressure through a blood pressure screening, or high cholesterol through an examination of blood chemistry, we can identify those who are at risk of suicide,” Hogan said. “Then, even more importantly, there are things that we can do that are effective. We’ve now got evidence that very brief, small interventions are quite effective in reducing rates of suicide.”

Hogan pointed to research demonstrating the effectiveness of patient screening for identifying suicidality, and of safety planning protocols for reducing suicide behaviors. He cited a 2013 study that looked at more than 75,000 patients who completed the PHQ-9 Patient Health Questionnaire, which found that 80 percent of the respondents who subsequently died by suicide had indicated elevated suicidal thoughts in the survey.

Another study Hogan cited showed a 45 percent reduction of suicide behaviors among patients who received safety planning. Still another study showed a 50 percent reduction in suicide deaths among patients receiving follow-up caring contacts from healthcare providers; caring contacts are phone calls, text messages, letters, or postcards, which are deemed to decrease isolation and increase connectedness.

For treatment of suicidal individuals, Hogan said, just as heart disease can be treated through interventional cardiology, suicidality can be treated with Cognitive Therapy for Suicidal Patients (CT-SP) and Dialectical Behavior Therapy (CBT).

Healthcare settings are ideal places for addressing suicide, Hogan said, because more than 80 percent of people dying by suicide and more than 90 percent of people attempting suicide had healthcare visits, and 40 percent had received emergency department care, in the prior 12 months; in the month before death, nearly half of those who died by suicide had a primary care visit, and nearly one-fifth had contact with mental health services.

“If we want to save lives from suicide, broader encouragement and action that focuses on suicide safe care especially in mainstream healthcare settings and most especially in capable or integrated primary care is our best bet,” said Hogan. “I would advocate that that would be the single most feasible effective action we could take to reduce rates of suicide.”

Pressing for suicide care in primary care practices, Hogan added, “It’s almost as if when it comes to suicide we don’t do anything except hope that people see a specialist. I’m going to make the argument that we now have tools for suicide care in primary care that are effective, comparable to things that we now do to care for the heart. So the argument is, let’s care for the brain the way we care for the heart.”

Hogan argued for a culture change in healthcare thinking about behavioral health treatment. “It’s an easily understandable but sad paradox from my point of view that care for the heart is very well established as a primary care responsibility—we know what the internist is supposed to do and what the cardiologist is supposed to do, and the lines of referral between the two are are pretty clear—but the care for the brain isn’t that well established.”

Hogan noted emerging evidence that Zero Suicide has reduced suicide rates where it has been adopted compared to usual care. For example, he said the Henry Ford Health System in Michigan achieved a 75 percent reduction; Centerstone in Tennessee a 65 percent reduction; and the Institute for Family Health in New York a 65 percent reduction.

READ MORE: The Zero Suicide Model in Tompkins County

If you or someone you know feels the need to speak with a mental health professional, you can contact the National Suicide Prevention Lifeline at 1-800-273-8255 or contact the Crisis Text Line by texting HOME to 741-741.