Zero Suicide: A National Perspective

Richard McKeon, Branch Chief for Suicide Prevention at the Substance Abuse and Mental Health Services Administration (SAMHSA), highlights that Goal 8 of the 2012 National Strategy for Suicide Prevention encourages healthcare programs to “explicitly adopt the goal of Zero Suicide.”

Goal 8, McKeon noted in “A National Perspective on Zero Suicide in Healthcare,” a presentation to the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30, was reiterated in the U.S. surgeon general’s “Call to Action” issued in January 2021.

“The public and private sector looked at where we were in terms of suicide prevention and came to the conclusion that it wasn’t that we needed a new strategy but rather we needed to be vigilant about implementing the strategy that we have and the things that we know work and bringing them to scale,” McKeon said. “One of those things was Zero Suicide.”

McKeon reviewed the core components of Zero Suicide:

McKeon also outlined Zero Suicide’s “pathway to care” model:

  • Create a leadership-driven, safety-oriented culture
  • Develop a competent, confident, and caring workforce
  • Identify and assess risk, by screening and assessing
  • Provide evidence-based care, including a safety plan, restricting lethal means, and treating suicidality directly with proven therapies
  • Provide continuity of care

“There needs to be agreed upon guidelines for care, such as those that Zero Suicide provides, around identifying and assessing suicide risk, what the approach is for screening, and then for those who are identified as being at risk for suicide an approach to assessment, and that they have access to evidence-based care,” McKeon explained.

Part 3 in a Series about the Zero Suicide Model for Healthcare

McKeon pointed to the use of recent assessment and treatment tools, such as the PHQ-9 Patient Health Questionnaire, C-SSRS Baseline Screening, and the Brown Stanley Safety Plan; and to several therapies for treating suicidality directly: Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), Collaborative Assessment and Management of Suicidality (CAMS), and the Attempted Suicide Short Intervention Program (ASSIP).

He highlighted restricting access to lethal means as a key evidence-based protocol of care that should be systematically adopted. He also noted that Zero Suicide protocols steer clinicians away from harmful practices.

 “For years, clinicians were relying on what were called ‘no suicide’ contracts because we weren’t providing them with anything better to utilize in working with people who were at high risk,” he said. “We know that ‘no suicide’ contracts were not only not effective, there was some evidence that they were counterproductive because patients in some sense accurately perceived they were more about the clinician or the system’s desire for protection from liability than it was about them and their pain. And of course it wasn’t effective to protect against liability, either.”

Another practice that Zero Suicide warns against, McKeon said, is directing healthcare clients to fill out a Patient Health Questionnaire that omits the question about suicidal thoughts and self-harm. “Dropping the suicide question is like putting on the medical chart, ‘If this patient is suicidal, we don’t want to know,’” he said.

Research supports the value of providing continuous contact and care for suicidal individuals, McKeon said. For example, he said that a survey of healthcare clients’ perceptions of care published by Columbia University researchers showed that 58.9 percent felt that follow-up phone calls helped “a lot” in stopping themselves from taking their own lives, and 21 percent said the calls helped “a little.”

“Ubiquitous and inexpensive technology is changing nearly every other industry,” McKeon said. “At a time when we can track a package halfway around the world, it should be unacceptable in the United States of America for us to lose track of people at high risk for suicide within the lethal gaps in many of our systems.”

McKeon said he understood why the idea of Zero Suicide has been controversial, with skeptics saying “we’re never going to be able to get there.” He said he empathized with a feeling among family members as well as clinicians who have lost loved ones or patients that Zero Suicide suggests that they should have been able to prevent the deaths. “That’s not at all what we mean, we sometimes talk about the preventability of suicide in too quick a way,” he said.

McKeon argued that Zero Suicide is an important goal representing “an assault on the fatalism around suicide that has held us back for many years, including in mental health components… What we mean is that no suicide is fated, no suicide is predestined, no matter how high the risk, until the person takes that final fatal step. There is always hope that they can be averted from that trajectory.”

A core belief of Zero Suicide is that the mission cannot be left to the efforts of an individual clinician but rather requires the dedication of the entire healthcare system, he stressed.

“When we say [suicide prevention] is a core responsibility of healthcare, it is really important that that’s not misinterpreted as the responsibility of individual clinicians,” McKeon said.

“For too long, but it is now changing with Zero Suicide, suicide prevention depended on the heroic efforts of individual clinicians or crisis staff, and many tried heroically to save lives and did save lives. But they were not backed up by a systematic approach within their system. It’s that systematic approach that really works.

“There’s a protocol for care for people who have been identified at higher risk, and there is consensus about how to assess the risk and about the treatments that can effective. That’s what Zero Suicide is about.”

McKeon outlined various other recent steps the federal government has taken to advance suicide prevention. He cited provisions in the 21st Century Cures Act of 2016 that authorized the National Suicide Prevention Lifeline into law for the first time and reauthorized the Garrett Lee Smith Memorial Act that provides grants for youth suicide prevention.

He outlined some of the progress being made in implementing Zero Suicide across the United States. He said SAMHSA has provided 35 Zero Suicide grants, and that implementation is underway in the Indian Health Service and the Air Force.

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.