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.
“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.
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.
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.
C. Edward Coffey, a professor of Psychiatry and Behavioral Sciences at the Medical University of South Carolina, begins his presentation with a statement that is both a troubling snapshot and a call to action: “We have a real crisis in this country with regard to suicides.”
Coffey cited the landmark “Crossing the Quality Chasm: A New Health System for the 21st Century,” a damning report by the Institute of Medicine two decades ago, for helping lay the foundation for Zero Suicide, a model aimed at preventing suicides among patients in healthcare systems.
“Our thought leaders are saying back in 2001 that our system is broken,” Coffey said. “And, furthermore, it is so badly broken that we’re not going to fix it by tweaking at the margins. We need to basically tear it up and start over. Remember, this criticism is not coming from a fringe group, but was authored by the thought leaders in international healthcare.”
Part 1 in a Series about the Zero Suicide Model for Healthcare
Coffey pointed to 2021 research published by the Commonwealth Fund showing how the United States ranked “dead last” among well developed high income nations in overall healthcare, access to care, administrative efficiency, equity, and outcomes. The same research, he noted, found that the U.S. ranks dramatically lower than the other nations in value for money spent on healthcare. “Although the Chasm report was written 20 years ago and it bemoaned our healthcare system then, the unfortunate news is that problems persist,” he said.
The Chasm report described six dimensions of ideal healthcare, Coffey explained; “healthcare should be safe, effective, patient-centered, timely, efficient, and equitable.”
He took up the challenge himself by becoming a leader in developing what has become known as the Zero Suicide Model, designed to prevent suicide deaths through systemic quality improvements within healthcare systems. In the early 2000s, Coffey led the Perfect Depression Care Initiative at Michigan’s Henry Ford Health System. The initiative achieved an 80 percent reduction in suicide deaths among Henry Ford patients including a decline to zero suicides in some annual reporting periods.
With a grant from the Robert Wood Johnson Foundation, the initiative sought to apply perfection goals for suicide prevention to the Chasm report’s elements of ideal healthcare. It began by applying the audacious goal of eliminating suicides to the element of effective care. Other goals included eliminating medication errors and achieving 100 percent patient satisfaction in the areas of patient-centered care, timely care, efficient care, and equitable care.
Coffey stressed that improving suicide care requires creating a “just culture” in the healthcare workplace, a “culture in which mistakes and errors are viewed as system issues, not personal failings, [and] are viewed as opportunities for learning and for improving the system, not punishing people. It’s profoundly important. We can’t ask our teammates to go up to plate and try to hit a home run every time, and then turn right around and punish them for striking out.”
Zero Suicide protocols that grew from the Henry Ford experiment include leadership of a system-wide culture change committed to reducing suicides, training a competent workforce, identifying individuals at risk with comprehensive screening and assessment, engaging at-risk individuals with care management plans, treating suicidal thoughts and behaviors with evidence-based treatments, and transitioning patients through care with warm hand-offs and supportive contacts.
Addressing colleagues who bemoan the immense challenges of preventing suicide deaths, Coffey recalled the internal discussions in developing the Perfect Depression Care Initiative at Henry Ford.
“What number of suicides are we going to tolerate? Is 12 suicides a year the right number? Is that numbering your parent or my sister? We realized that the only answer to this question is zero. Our goal has to be zero. And at that moment, our department was transformed. We stopped trying to be the best, we stopped trying to improve incrementally, and we began to strive for perfection in all of our goals. What does it mean to be the best in a mediocre industry? ‘Being the best’ isn’t good enough. We’ve got to pursue perfection.”
Coffey emphasized the importance of leadership in implementing the Zero Suicide Model. “Leadership involvement is essential to the success of this kind of work,” he said. “This cannot be the flavor of the month. It can’t be the quality improvement project of the month. It has to be a system-wide initiative.”
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.
Jenna Heise, who became the director of suicide prevention implementation for New York State earlier this year, tells of a powerful moment in her work during her previous position at Texas Health and Human Services.
She was attending a high school event in Corpus Christi where a young man spoke. He had been treated for suicidality at a hospital that practiced Zero Suicide, a suicide prevention model for healthcare systems. “The principal come up and said, with tears in her eyes, ‘That young man, he’s alive because of you,’” Heise recalled.
Heise, widely recognized for her work in advancing the Zero Suicide Model in Texas and beyond, related the story during “Call to Action: Suicide Prevention in Healthcare,” a special presentation on the Zero Suicide Model for Tompkins County’s healthcare leaders sponsored by The Sophie Fund on November 16. The presentation via Zoom was attended by senior leaders from 11 hospitals, college health centers, and community behavioral health services, and a representative of the Tompkins County Suicide Prevention Coalition.
Heise used her Corpus Christi story to illustrate the potential of the Zero Suicide Model. “I did this in Texas, across 254 counties, in a statewide effort,” she said. “I know that you can do this. Yes, it works. I can’t tell you how many times I have heard from staff, how many times I’ve been on calls where I’ve heard from loved ones.”
She pointed to healthcare systems where Zero Suicide has been implemented with success, notably the Henry Ford Health System in Michigan. She said that within four years the suicide rate among its patients decreased by 75 percent. In some years the system recorded zero suicide deaths compared to an average 89 suicides per year previously.
Citing data that shows rising death rates, Heise called suicide a “public health crisis.” She said suicide was the second leading cause of death in the U.S. for people in the 10-14, 15-24, and 25-34 age groups, and the 10th leading cause of death overall. She referenced local data indicating that Tompkins County has averaged 12 suicide deaths per year in the past five years, and noted that each suicide tragedy impacts many other individuals such as family members, friends, colleagues, and peers.
Heise said that healthcare providers have traditionally treated suicidal patients in a fragmented approach, whereas the Zero Suicide Model brings together a framework of best practices for a more effective safety net for suicidal individuals seeking professional healthcare. The framework, she added, is based on “mind blowing” research into how to prevent suicide deaths.
“We don’t have to wonder what works,” she said. “We don’t have to throw the kitchen sink at it anymore. We can know what works, and we can use that.” She compared the promise of working more confidently with the Zero Suicide Model with her own experience as a young clinician, when she felt like “a deer in the headlights” when confronted with treating people who had made a suicide attempt.
She argued that it makes sense for prevention efforts to focus on medical providers because so many people who take their own lives are seeing healthcare professionals. She said that 80 percent of people who died by suicide had a healthcare visit in the year before their death. Forty-five percent had a primary care visit, 37 percent an emergency department visit, and 20 percent contact with a mental health service.
Heise quoted Michael Hogan, a former mental health commissioner for New York State and a co-developer of the Zero Suicide Model, saying, “We should treat suicide prevention in health care systems as we treat heart attack prevention.”
Heise walked the Tompkins healthcare leaders through the elements of the Zero Suicide framework, starting with the critical importance of top leadership. “When we talk about leadership, we’re talking about buy-in from the top down,” she explained. “We have to have leaders. Without every level of the agency working together with a consistent message and plan, it’s doomed to fail.”
Training staff in using evidence-based tools is essential, Heise said. She highlighted the importance of properly using the correct screening and assessment tools to identify suicidal individuals and provide them with an appropriate care plan. She noted that the model also calls for engaging patients through developing safety plans that provide them with coping skills for averting crises, and for the use of proven therapies for directly treating suicidality, such as Cognitive Behavioral Therapy for Suicidal Patients (CT-SP).
Ensuring safe transitions through care is another key element of the model, Heise said. This involves “warm handovers” when additional professional services are needed, and following up with suicidal individuals with “caring contacts” such as emails, texts, or postcards. Finally, she said, Zero Suicide calls for continuous attention to improving policies and procedures through data collection and other assessment measures.
“It’s a bundle of best practices that you use from the minute you meet the patient, all the way through their intake, their time with you, they’re getting ready to leave, and then the time they leave their care with you,” Heise said. “And then you follow up with them. It’s the entire continuum of care.”
Heise encouraged providers who have not already embarked on implementing the Zero Suicide Model to begin the process by conducting the Organizational Self-Study and Workforce Survey found in the model’s toolkit.
“Look at your organization as a whole, and where you are with certain best practices for suicide care,” she said. “The work force study is where you send out this blanket survey to all of the folks at your agency, to let you know what they know and don’t know.”
Heise said that Zero Suicide promotes a “just culture” in healthcare because it emphasizes the role of the system rather putting responsibility for suicide care and suicide deaths on individual clinicians. “We call it a preventable death, and what we mean by that is not that any of us could have stopped somebody from dying by our single efforts,” she said. “This is really looking at the bigger picture.”
Following Heise’s presentation, Scott MacLeod, co-founder of The Sophie Fund, announced planning for follow-up events to advance the Zero Suicide Model in Tompkins County; they included an expert briefing for healthcare managers and an introductory presentation for primary care practices.
The Sophie Fund proposed that Tompkins County healthcare leaders begin a formal and regular dialogue on Zero Suicide to share ideas and experiences, and to work on securing funding for a county implementation coordinator and training programs, MacLeod said.
He acknowledged the tremendous pressures and stress on healthcare providers amid the Covid-19 pandemic, but expressed hope that leaders will respond to the “Call to Action” with further efforts to implement the Zero Suicide Model.
“We are grateful for your work to improve suicide care in Tompkins County,” he said. “We invited our community’s top healthcare leaders to this ‘Call to Action’ today because leadership is the number one element of the Zero Suicide Model.”
The Sophie Fund launched a Zero Suicide initiative in 2017 by organizing an expert briefing on the model for local healthcare leaders. In 2017, the model was recommended by the Tompkins County Suicide Prevention Coalition and endorsed by the Tompkins County Legislature.
Among those attending Heise’s presentation were Frank Kruppa, director of the county Health Department and commissioner of Mental Health Services, and Harmony Ayers-Friedlander, deputy commissioner.
Other agencies represented were Cayuga Medical Center; Cayuga Health Partners; Guthrie Cortland Medical Center; Suicide Prevention and Crisis Service; Family & Children’s Service of Ithaca; MindWell Center LLP; REACH Medical; Cornell Health, Cornell University; Center for Counseling and Psychiatric Services, Ithaca College; and Health and Wellness Services and Mental Health Counseling, Tompkins Cortland Community College.
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.
Attention Tompkins County mental health professionals! If you missed the 2021 Suicide Prevention Summit on July 24-25, there’s an easy way to catch up with all ten 1-hour sessions presented by some of the field’s leading experts.
Here’s how: Register retroactively for the Summit at https://www.mentalhealthacademy.net/suicideprevention. Upon registration, you will receive an email with instructions to access on-demand video recordings and PDFs of all the presentations. Note: the portal will be available until the end of September 2021. See details of the Summit below.
“Innovation in Men’s Mental Health: Using Humor, Media and Digital Engagement to Promote Mental Health and Prevent Suicide for High Risk Men,” by Sally Spencer-Thomas, Psy.D.
“A Strengths-based Approach to Suicide Assessment and Treatment,” by Prof. John Sommers-Flanagan, Ph.D.
“Managing Hopelessness, Helplessness and Despair with our Younger Clients,” by Bonnie Goldstein, Ph.D.
“Planning for Safety and Post-traumatic Growth,” by DeQuincy Lezine, Ph.D.
“Perception is Everything: Stigma, Mental Health, & Suicide in Historically Marginalized Communities,” by Victor Armstrong
“Rethinking Suicide: Implications for Military Personnel and Veterans,” by Prof. Craig Bryan, Psy.D.
“Contemporary Clinical Suicide Prevention,” by Prof. David A. Jobes, Ph.D.
“Creating a Suicide-safe Culture with Zero Suicide,” by Wykisha McKinney
“Addressing Youth Depression and Suicidal Ideation in a Post- Pandemic World,” by Prof. Cirecie West-Olatunji
“Psychosocial Interventions for Suicidal Youth and their Families,” by A/Prof. Jonathan Singer, Ph.D.
U.S. Surgeon General Jerome Adams on January 19 issued a “Call to Action” report to implement the 2012 National Strategy for Suicide Prevention, a detailed roadmap for preventing suicide in a comprehensive and coordinated way. “Much remains to be done,” the report warned. “Suicide prevention continues to lack the breadth and depth of the coordinated response needed to truly make a difference in reducing suicide.”
The report noted a new urgency behind suicide prevention efforts: the COVID-19 pandemic has now created conditions that may further suicide risk, such as increased social isolation, economic stress, and reduced access to community and religious support. “Problems resulting from the pandemic—including physical illness, loss of loved ones, anxiety, depression, job loss, eviction, and increased poverty—could all contribute to suicide risk,” Adams said.
The report said that in 2019 more than 47,000 Americans died by suicide, and that the national suicide rate increased 32 percent—from 10.5 to 13.9 per 100,000 people—in the 20-year period from 1999 to 2019. The report notes that for every person who dies by suicide, thousands more experience suicidal thoughts or attempt suicide—in a 2019 survey, 1.4 million U.S. adults reported attempting suicide in the past year and 3.5 million adults reported making a suicide plan.
“Although research has identified many strategies that can be effective in preventing suicide, these evidence-informed approaches have not yet been brought to scale,” the report said. Indeed, it added, an assessment of progress toward implementation of the National Strategy showed that few efforts have been comprehensive or strong enough to have a measurable impact on reducing suicidal behavior.
[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.]
The report highlights the Zero Suicide Model as one of the key instruments for saving lives. In 2018, the Tompkins County Suicide Prevention Coalition and the Tompkins County Legislature endorsed the model, which incorporates recommendations for “a gold standard of care for people with suicide risk.” The model stresses the need to include suicide prevention as a core component of all health care services, rather than limit it to services provided by mental health specialists, and to improve professional and clinical training and practice for preventing suicides.
The report calls for increased use of a key component of the Zero Suicide Model: a suicide safe care pathway, to ensure that patients at risk for suicide are identified and provided with continuing care tailored to their needs.
“All patients are screened on past and present suicidal behavior, and positive screens are followed by a full assessment. Individuals identified as being at increased risk are entered into a suicide safe care pathway, thus ensuring that they are provided with the attention and support they need to stay safe and recover.
“Components include periodic assessments of suicidality and ongoing follow-up, including contacting patients who fail to show up for an appointment or withdraw from care. The inclusion of family members and other identified support persons in pathway implementation may help support patient engagement.
“Implementation of a suicide safe care pathway requires that protocols and systems be in place to collect and analyze data to track services, ensure patient safety, and assess treatment outcomes. The system should collect data on process measures, such as screening rates, safety planning, and services provided; care outcomes; suicide attempts and deaths; and any other relevant factors, such as sociodemographic characteristics, clinical history, and referrals to other sources of care.
The report noted that in response to the need for a minimum standard of care for individuals at risk for suicide, the National Action Alliance for Suicide Prevention in 2018 developed Recommended Standard Care for People with Suicide Risk: Making Health Care Suicide Safe. It identifies individual recommended practices—such as screening and assessment for suicide risk, collaborative safety planning, treatment of suicidality, and the use of caring contacts—that can be adopted in outpatient mental health and substance misuse settings, emergency departments, and primary care.
The surgeon general’s Call to Action states that while that all 13 goals and 60 objectives of the 2012 National Strategy remain relevant, it is time to focus on six key actions in order to reverse the current upward trend in suicide deaths in the United States.
The Call to Action identifies four strategic directions: Healthy and Empowered Individuals, Families, and Communities; Clinical and Community Preventive Services; Treatment and Support Services; and Surveillance, Research, and Evaluation.
Within those directions, the Call to Action identifies six main actions to pursue:
Activate a broad-based public health response to suicide
Address upstream factors that impact suicide
Ensure lethal means safety
Support adoption of evidence-based care for suicide risk
Enhance crisis care and care transitions
Improve the quality, timeliness, and use of suicide-related data
Action 1. Activate a Broad-Based Public Health Response to Suicide: Inspire and empower everyone to play a role in suicide prevention.
1.1 Broaden perceptions of suicide, who is affected, and the many factors that can affect suicide risk.
1.2 Empower every individual and organization to play a role in suicide prevention.
1.3 Engage people with lived experience in all aspects of suicide prevention.
1.4 Use effective communications to engage diverse sectors in suicide prevention.
Action 1: Priorities for Action
State government and public health entities should implement the Suicide Prevention Resource Center’s Recommendations for State Suicide Prevention Infrastructure to support comprehensive (i.e., multi- component) suicide prevention in communities.
Prevention leaders from the public and private sectors, at all levels (national, state, tribal, and local), should align and evaluate their efforts consistent with the Centers for Disease Control and Prevention (CDC) resource Preventing Suicide: A Technical Package of Policy, Programs, and Practices, to expand the adoption of suicide prevention strategies that are based on the best available evidence.
Federal agencies and state, tribal, local, and county governments and coalitions should strengthen their prevention efforts by developing strategic suicide prevention plans based on available public health data. Mechanisms for the prompt sharing of innovations and best practices should be developed and supported.
State and local suicide prevention coalitions and health systems should actively reach out to organizations serving populations at high risk for suicide; these systems should also reach out to individuals with lived experience in order to learn from them and engage them in designing prevention efforts.
The public and private sectors should invest in patient-centered research and include people with lived experience in research design and implementation.
Federal agencies, mental health and suicide prevention non-governmental organizations, and others conducting communication efforts should ensure that suicide prevention communications campaigns (1) are strategic, (2) include clear aims for behavior changes that support broader suicide prevention efforts, and (3) measure their impact.
The federal government (Congress) should expand and sustain support for states, territories, communities, and tribes to implement comprehensive suicide prevention initiatives similar to the Comprehensive Suicide Prevention Program, funded by CDC, and the Garrett Lee Smith youth suicide prevention grants, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), which have been shown to reduce suicide in participating counties, particularly in rural areas. Funding targeting substance use disorder should be broad enough in scope to allow for interventions that address suicide prevention and related workforce and infrastructure needs.
Action 2. Address Upstream Factors that Impact Suicide: Focus on ways to prevent everyone from suicide.
2.1 Promote and enhance social connectedness and opportunities to contribute.
2.2 Strengthen economic supports.
2.3 Engage and support high-risk and underserved groups.
2.4 Dedicate resources to the development, implementation, and evaluation of interventions aimed at preventing suicidal behaviors.
Action 2: Priorities for Action
Private companies and workplaces should leverage their health care benefits purchasing power to enhance employee mental health (e.g., invest in benefits and programs to prevent and treat behavioral health problems) and work to shape worksite values and culture to promote mental health by providing access to crisis support, support to employees following a suicide, and ongoing mental health wellness programming.
Suicide prevention leads in federal, state, tribal, and local public health and behavioral health agencies should partner with their counterparts in labor and workforce, housing, health care, and other public assistance agencies to collaborate on strengthening economic supports for families and communities.
Foundations and other philanthropic organizations that support early intervention programs— particularly those targeting (1) social determinants of health (e.g., reducing poverty and exposure to trauma, improving access to good education and health care, improving health equity) and/or (2) enhanced social interactions (e.g., improved parenting skills) and problem-solving and coping skills— should ensure that these programs include outcomes related to suicide (e.g., ideation, plans, attempts) and evaluation of those programs for suicide-related outcomes.
Federal government and private sector research funders should support the analysis of existing data sets of longitudinal studies to determine the impact of various interventions (e.g., home visitation, preschool programs, substance misuse, child trauma) on suicidal ideation, plans, and attempts, and on deaths by suicide. This could include such projects as the CDC’s efforts to assess and prevent adverse childhood experiences and examine their effect on suicide-related problems, and National Institutes of Health (NIH) initiatives that focus on aggregating prevention trial data sets to better understand the long-term and cross-over effects of prevention interventions on mental health outcomes, including suicide risk,88 and to address suicide research gaps.
Action 3. Ensure Lethal Means Safety: Keep people safe while they are in crisis.
3.1 Empower communities to implement proven approaches.
3.2 Increase the use of lethal means safety counseling
3.3 Dedicate resources to the development, implementation, and evaluation of interventions aimed at addressing the role of lethal means safety in suicide and suicide prevention.
Action 3: Priorities for Action
The federal government and private sector entities can support efforts to ensure that updated information on lethal means safety policies, programs, and practices (e.g., ERPOs, firearm owner and retailer education, bridge barriers, medication packaging, carbon monoxide shut-off sensors in vehicles) is incorporated into existing national clearinghouses and resource centers so that local municipalities, states, and tribes can adopt and evaluate them for their prevention benefits.
States, communities, and tribes should collaborate with the private sector to increase awareness of and take action to reduce access to firearms and other lethal means of suicide, including opioids and other medications, alcohol and other substances or poisons, and community locations (e.g., railways, bridges, parking garages) where suicidal behaviors have occurred. This urgent multi-sector effort is key to saving lives by reducing access to lethal means for individuals in crisis.
Health systems and payers should leverage their existing training and resources and collaborate on a national initiative to train general and specialty health care providers and care teams on safety planning and lethal means counseling.
SAMHSA and the VA should coordinate to ensure that lethal means safety assessment and counseling are incorporated into the assessment and intervention procedures of the National Suicide Prevention Lifeline and Veterans Crisis Line call centers, particularly in preparation for the national launch of 988.
The federal government can prioritize and fund research and program evaluation analyzing community and clinical lethal means safety interventions (e.g., ERPOs, firearm owner and retailer education, bridge barriers, medication packaging, carbon monoxide shut-off sensors in vehicles) at the population level.
State and federal governments should collaborate with the private sector on a synchronized public health communication campaign addressing lethal means safety in the context of suicide prevention, which should then be evaluated to determine prevention benefits and inform future communication efforts.
Action 4. Support Adoption of Evidence-Based Care for Suicide Risk: Ensure safe and effective care for all.
4.1 Increase clinical training in evidence-based care for suicide risk.
4.2 Improve suicide risk identification in health care settings.
4.3 Conduct safety planning with all patients who screen positive for suicide risk.
4.4 Increase the use of suicide safe care pathways in health care systems for individuals at risk.
4.5 Increase the use of caring contacts in diverse settings.
Action 4: Priorities for Action
The federal government, professional associations, and accrediting bodies should collaborate to address barriers to adopting the Action Alliance’s Suicide Prevention and the Clinical Workforce: Guidelines for Training to ensure increased clinical training in evidence-based care for suicide risk during graduate education and post-graduate training.
State behavioral health licensing boards should add continuing education requirements for suicide prevention in order for clinicians to maintain licensure or certification.
Payers from the public and private sectors should incentivize the delivery of evidence-based care via existing levers in contracting and reimbursement.
Federal and state policymakers and commercial payers and health systems should take specific steps to improve outcomes for individuals with mental health and substance misuse conditions in primary care by using effective methods (e.g., CoCM) to integrate mental health and substance misuse treatment into primary care.
To enhance workflows for suicide safe care, health systems should collaborate with EHR vendors to develop options for integrating screening, suicide safe care pathways, and safety planning into their EHR systems.
Action 5. Enhance Crisis Care and Care Transitions: Ensure that crisis services are available to anyone, anywhere, at any time.
5.1 Increase the development and use of statewide or regional crisis service hubs.
5.2 Increase the use of mobile crisis teams.
5.3 Increase the use of crisis receiving and stabilization facilities.
5.4 Ensure safe care transitions for patients at risk.
5.5 Ensure adequate crisis infrastructure to support implementation of the national 988 number.
Action 5: Priorities for Action
The federal government and the private sector should address gaps, opportunities, and resource needs to achieve standardization among crisis centers in interventional approaches and quality assurance in preparation for the launch of 988.
The federal government, states, and the private sector should work together to optimize system design, system operations, and system financing for 988 as the hub of an enhanced, coordinated crisis system, and enhance coordination between Lifeline 988 centers and 911 centers to reduce overreliance on 911 services and ED boarding (the practice of keeping admitted patients on stretchers in hallways due to crowding).
The federal government should fund the necessary infrastructure to support crisis care (e.g., Congressional support for the 5 percent SAMHSA Mental Health Block Grant set-aside; core services identified in SAMHSA’s National Guidelines for Behavioral Health Crisis Care) and should provide technical assistance to states looking to evolve crisis systems of care.
The federal government and foundations should support research to identify effective models of mental health crisis response (e.g., coordinated efforts among mental health specialists, peers, and law enforcement) to improve short- and long-term effects on communities of color and other marginalized populations.
The federal government and private sector payers should support the use of follow-up phone calls or texts within 24 hours of discharge from psychiatric hospitalization or emergency room discharge to check in with the patient, provide support, and maintain contact until the person’s first outpatient appointment.
The federal government should establish universally recognized coding for behavioral health crisis services, and public and private sector partners should collaborate with payers and health systems to increase adoption of the new coding.
The federal government should support the development of an essential benefits designation that will encourage health care insurers to provide reimbursement for crisis services, thus reducing the financial burden on state and local governments to pay for those services, delivered within a structure that supports the justice system and ED diversion.
Action 6. Improve the Quality, Timeliness, and Use of Suicide-Related Data: Know who is impacted and how to best respond.
6.1 Increase access to near real-time data related to suicide.
6.2 Improve the quality of data on causes of death.
6.3 Expand the accessibility and use of existing federal data systems that include data on suicide attempts and ideation.
6.4 Improve coordination and sharing of suicide-related data across the federal, state, and local levels.
6.5 Use multiple data sources to identify groups at risk and to inform action.
Action 6: Priorities for Action
The federal government should support near real-time collection of data on deaths by suicide and nonfatal suicide attempts in a group of sentinel states to develop the framework for a national early warning system for suicidal behavior in the U.S. The system would create a central database that links multiple data sources and would build state and local capacity to translate data trends into prevention efforts in a timely manner. In addition, the federal government should expand ED SNSRO to monitor nonfatal suicide-related outcomes, track spikes and potential clusters in suicide attempts, and identify patterns, all of which can then inform prevention activities.
The public and private sectors should collaborate on a near real-time suicide dashboard that pulls data from existing national, state, tribal, and community databases to make data on deaths by suicide and suicide attempts timelier and more accessible, thus linking the dashboard to prevention actions on the ground.
The federal government should implement Recommendation 1.8 of the Interagency Serious Mental Illness Coordinating Committee, which calls on public and private health care systems to routinely link mortality data for serious mental illness (SMI) and serious emotional disturbance (SED) populations, and supports the standardization of similar data gathering across state and local systems for SMI and SED populations within the justice system.
Professional organizations connected to coroners and medical examiners at the state and national levels should release guidance on and support wide-scale implementation of coding sexual orientation and gender identity in death investigations.
The federal government should implement the PREVENTS Executive Order recommendation for the U.S. Department of Health and Human Services and the VA to propose legislative changes that mandate a standardized process for uniform ED data reporting across the United States specific to the external cause of injury (e.g., suicide attempt).
Health care systems should work with public sector agencies to support the linkage of mortality data with health record, social, geographic, education, and criminal justice data systems to strengthen data quality and increase accountability for patient outcomes across key systems.
State suicide prevention coordinators and community suicide prevention leaders should routinely monitor available data to identify trends and evaluate their own efforts.
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