Town Hall: How Healthcare Helps Prevent Suicides

The Tompkins County Suicide Prevention Coalition will host “How Healthcare Helps Prevent Suicides,” a community town hall to discuss local efforts to implement the “Zero Suicide” model for improving healthcare support for at-risk individuals.

The town hall, at the Greater Ithaca Activities Center (GIAC) on September 28 from 5:30 p.m. – 7:30 p.m., will feature panel discussions about why suicide is a public health challenge and how the Zero Suicide model is used by healthcare systems to prevent suicide deaths.

Whole Health Commissioner Frank Kruppa will kick off the town hall with opening remarks.

Organizations serving as presenters and panelists include: Tompkins County Mental Health Services; Cayuga Health System; Cayuga Medical Associates; Guthrie Medical Group, Cortland; Cornell University; Ithaca City School District, Alcohol and Drug Council; U.S. Department of Veterans Affairs; Suicide Prevention & Crisis Service (988 Call Center); Cayuga Addiction Recovery Services; Smile Through the Storms; and The Sophie Fund.

In addition, Coalition work groups will give brief presentations on their work to improve suicide data collection and analysis, prevent suicides among young people, and reduce access to lethal means within at-risk populations.

Several local mental health agencies and organizations will provide information tables with staff who can answer questions. They include: Tompkins County Whole Health; Tompkins County Office of Veterans Services; U.S. Department of Veterans Affairs; Mental Health Association in Tompkins County; Suicide Prevention & Crisis Service (988 Call Center); American Foundation for Suicide Prevention Greater Central New York; and the National Alliance on Mental Illness Finger Lakes.

Zero Suicide is an emerging suicide prevention model designed to save lives by closing gaps in suicide care in healthcare as well as behavioral health settings.

The model calls for systematic use of screening for self-harm, safety planning for patients deemed at risk, referrals to appropriate levels of further care, safe transitions of care between providers, and evidence-based treatment for suicidality, among other tools.

“We recognize the critical role of healthcare in preventing suicide deaths,” said Zoe Lincoln, Whole Health Planner with Tompkins County Whole Health and Coordinator of the Tompkins County Zero Suicide Steering Committee, a collaborative group of local healthcare leaders. “The Town Hall highlights county-wide dedication to saving lives through evidence-based best practices, via the Zero Suicide Model. Together, we strive to elevate the standard of care and support for our community members in need.” 

Implementation of Zero Suicide across local healthcare is one of the objectives listed in the Coalition’s 2022-2025 Strategic Plan. In 2022, leaders from community and campus healthcare providers formed the Tompkins County Zero Suicide Steering Committee to lead and coordinate efforts.

The Tompkins County Suicide Prevention Coalition was formed in 2017 and is comprised of health agencies, community organizations, and individual members who share a determination to prevent suicide deaths in the community.

“We are excited to present this Town Hall with a focus on Zero Suicide,” said Sally Manning, Racker Program Director and convenor of the Coalition. “We recognize suicide as a serious public health concern. The Coalition has a vision for our community where no lives are lost to suicide. This is a chance to learn more about suicide prevention and what we can all do to help those who may be struggling.”

The Sophie Fund has encouraged Tompkins County providers to work toward implementing the Zero Suicide model, beginning with a presentation by leading experts for healthcare leaders in October 2017. The Sophie Fund then sponsored a series of five presentations and trainings on Zero Suicide for healthcare leaders and clinicians in 2021-22.

Zero Suicide Model Expert to Tompkins Healthcare: “The Time is Now”

A top expert urged Tompkins County healthcare leaders on August 9 to pursue implementation of the Zero Suicide Model, a framework designed to prevent suicide deaths by closing gaps in the care provided by healthcare systems.

Brian Ahmedani, suicide prevention expert at the Henry Ford Health System

Brian Ahmedani, director of the Center for Health Policy & Health Services Research at the Henry Ford Health System, said Zero Suicide has proved to be highly effective in Henry Ford’s pioneering work on the model over the past two decades. During a period between 2008 and 2010, he said, not a single Henry Ford behavioral health patient died by suicide.

Citing the continuing rise in the U.S. suicide rate in the past 20 years, Ahmedani said research now shows that healthcare systems can play an important role in reversing that trend..

 “We need to do something about this, and the time is now,” he said. “So your charge is to map out a perfect system of care, develop processes and policies that align with that perfect system of care, and figure out who is going do each part of that system of care.”

Ahmedani made his remarks in a presentation to the Tompkins County Zero Suicide Steering Committee, a group of healthcare leaders formed in 2022 to work on implementing the model within and across healthcare systems serving the community. The presentation was sponsored by The Sophie Fund.

Ahmedani explained that the Zero Suicide model for healthcare as well as behavioral health settings entails patient screening, risk assessment, and care coordination.

It starts with systematic screening of all patients using evidence-based tools to determine if they have any suicide risk. If a patient screens positive, then a risk assessment is conducted to determine the onward care that is aligned with their level of risk. Zero Suicide calls for care coordination to avoid system gaps, and for the use of evidence-based treatments for suicidality such as Cognitive Behavioral Therapy.

Ahmedani said that the model calls for the provider and an at-risk patient together to develop a safety plan, a quick guide to help in a crisis that includes their personal warning signs, coping strategies, emergency contacts, and reminders of how to stay safe away from lethal means. Just the safety plan along with a follow-up caring contact message with a patient reduces suicide risk by 20 percent, he said.

“When somebody has suicidal ideation, it’s sort of like having paralysis of your brain, your body shuts down and it can only think of this escape pathway. So if you have a rehearsed plan, they know what they can do instead. If they don’t have a plan, that’s when they continue to get stuck in this this fixation when this intense wave of wanting to hurt yourself comes over your brain and takes over,” he said.

Explaining Zero Suicide’s inclusion of healthcare settings, Ahmedani noted that until 2012 conventional wisdom felt that suicide prevention was a mission left to the behavioral health field.

But he said that research indicates that more than 83 percent of people who died by suicide had made some type of healthcare visit in the weeks and months prior to their death; 92 percent of people making a suicide attempt had seen a healthcare provider very recently. Moreover, he added, studies now show that more than half of the people who die by suicide had no mental health diagnosis.

“That means they’ve never received psychotherapy, they’ve never come in for a suicide attempt in the past, there is no evidence of mental health diagnosis in their entire clinical history,” Ahmedani said.

“What that means is that we need different approaches for suicide prevention. We can’t just rely on waiting for someone to get a mental health diagnosis before we think about suicide prevention. Most people are connecting with healthcare systems before they’re dying. They’re right in front of us.”

Ahmedani said that primary care practices are an important setting for identifying people at risk who may never have sought mental health treatment.

“Most people are actually going to primary care before they’re dying by suicide. If we don’t do anything in primary care, we won’t be able to reach the vast majority of people who are right in front of us before they’re dying by suicide.”

Ahmedani said that behavioral health settings continue to be critical for preventing suicide, because patients with a mental health diagnosis are already known to be at an elevated risk. “But even if we provided perfect care in behavioral health, we could only reach about one third of the people who are dying by suicide,” he said.

Another argument for all healthcare settings also playing a role, Ahmedani said, is a realization that suicidality is not a symptom of a disease like depression but is actually its own disease that needs to be identified and treated as a comorbid condition.

“We really need to think more broadly than that it’s just some symptom of depression or symptom of substance use or symptom of something else, and that if we treat that thing then the suicide risk will go away. We actually have to treat those things concurrently. Both things need to be treated,” he said.

Ahmedani said that unlike longstanding strides to prevent cardiovascular disease, most of the effective interventions outlined in the Zero Suicide Model have only been developed by Henry Ford and others over the past two decades.

“The interventions really haven’t penetrated healthcare systems in the way that other disease treatments have,” he said. “But we have an opportunity to do that now. So I’m really encouraging us to think about how we can take advantage of it,” he said.

“This program is set up perfectly to structure within a healthcare system using pragmatic approaches and interventions that fit within healthcare so they don’t overburden the resources and staffing and all the costs. It  is designed to work effectively in your program.”

Ahmedani stressed the importance of creating a healthcare system team to lead implementation of Zero Suicide, as they did in pioneering the model at Henry Ford.

“Our major recommendation is that you start and launch these services with a team of people that can represent the different perspectives in your healthcare system,” he said. Henry Ford’s team included system leadership, clinicians from different levels, and patients “so that we could really design a system of care that works for everybody,” he said.

Creating system teamwork to prevent suicide deaths removes a burden of responsibility from “the individual heroic clinician who works 24 hours a day, seven days a week trying to stay up and do all these things,” he said. “If we work as a team, we can reduce burnout, we can be more effective, and we can deliver services that end up leading downstream to a better result in preventing suicide.”

Ahmedani said that after implementing Zero Suicide’s quality care process improvements, Henry Ford saw a 75-80 percent reduction in suicide deaths among behavioral health patients within the first year. He said that reduction would then be sustained for more than 22 years even as the U.S. and Michigan suicide rates continued to climb; during an 18-month period from 2008-2010, no behavioral health patients died by suicide.

“Without doing all these things, people fall through the cracks. People aren’t identified, they see multiple providers most of the time, they interact with our healthcare system in lots of different ways, and we don’t figure out who they are. If we do each of those processes, people don’t fall through the cracks,” he said.

“We’ve got a lot of data that show that this program works not only at Henry Ford but it works at a lot of different health care systems. The goal of Zero Suicide is that, instead of thinking that suicide is inevitable like we used to, we’re now thinking suicides are preventable.”

To the surprise of many, Ahmedani said, Henry Ford increased its behavioral health revenue eight-fold after implementing Zero Suicide by reformatting and restructuring the way that it provides care.

He said that medical practices utilizing collaborative care models are able to bill insurance for suicide prevention procedures like screening, risk assessment, and care coordination. He said Blue Cross in Michigan is leading a partnership with healthcare incentivizing or paying for suicide prevention procedures.

Ahmedani said about 50,000 people die by suicide in the United States each year but that the scope of the problem is even bigger. He said 2 million people in the U.S. make a suicide attempt every year, and 15 million are thinking about suicide at some point in the year.

“So we’re talking about somewhere between 4-5 percent of the U.S. general population who are affected by suicide during a year. That’s a lot of people,” he said.

He said that suicide is the only one of the 15 leading causes of death in the United States whose annual rate has been increasing. The annual rate increased 25-30 percent over the past two decades, he said.

Ahmedani said that a significant step forward occurred with the release of the 2012 National Strategy for Suicide Prevention, which drew on Henry Ford’s work and for the first time declared that suicide prevention should be a core component of healthcare services and not only behavioral health.

Afterwards, The Joint Commission, a leading healthcare accrediting body, issued recommendations for preventing suicide in healthcare settings and requirements for using the latest processes and intervention tools in behavioral health settings.

Ahmedani noted that some people in healthcare get “twitchy” about the seemingly unrealistic notion of aiming for zero suicide deaths. “The long-term aspirational goal is to prevent every suicide, but the operational goal is to implement a system of care that focuses on error reduction,” he explained.

He noted that “designing for zero” is a practice seen in many areas, such as surgical operating theaters, airline travel, automotive manufacturing, and nuclear power plants. Setting a goal of zero suicides maintains a focus on continuous quality improvement, he said, reducing the opportunity for complacency. “If we strive for any other number, then we aren’t moving towards the ultimate goal,” he said.

Ahmedani serves as chair of Michigan Governor Gretchen Whitmer’s Suicide Prevention Commission. Besides his work on Zero Suicide at Henry Ford, he is a principal investigator for a number of current clinical trials and studies around suicide and healthcare; one of them is evaluating the implementation of the Zero Suicide Model in various settings of six healthcare systems in five states serving 10 million patients a year.

The creation of the Steering Committee was a response to Goal 2 of the Tompkins County Suicide Prevention Coalition’s Three-Year Strategic Plan 2022-2025 adopted in February 2022. One of Goal 2’s objectives is to “form a Zero Suicide Work Group comprised of leading health and mental health providers to share ideas, experiences, and challenges, and lead collaborative, sustainable efforts to implement the Zero Suicide Model throughout Tompkins County.”

Tompkins County Zero Suicide Steering Committee Gets to Work

Top local healthcare leaders on November 10 held the first meeting of the Tompkins County Zero Suicide Steering Committee to implement the suicide prevention model within and across healthcare systems serving the community. The meeting was attended by 17 healthcare leaders representing 11 provider organizations.

The leaders agreed to form the Steering Committee last July while participating in “Zero Suicide Roundtable: A Discussion on Best Practices in Suicide Prevention with Tompkins County Healthcare Leaders.” The roundtable was hosted at the Statler Hotel by The Sophie Fund and Tompkins County Mental Health Services.

Tompkins County healthcare leaders roundtable July 20, 2022

The creation of the Steering Committee is pursuant to Goal 2 of the Tompkins County Suicide Prevention Coalition’s Three-Year Strategic Plan 2022-2025 adopted in February 2022. One of Goal 2’s objectives is to “form a Zero Suicide Work Group comprised of leading health and mental health providers to share ideas, experiences, and challenges, and lead collaborative, sustainable efforts to implement the Zero Suicide Model throughout Tompkins County.”

The Tompkins County Health Department provided a fellow, Zoe Lincoln, to serve as the Steering Committee coordinator to provide administrative, communications, and operational support. The Steering Committee agreed to regularly report back to the Coalition on its activities and results.

The Zero Suicide Model is an emerging standard designed to save lives by closing gaps in the suicide care offered by healthcare providers.

The model provides a practical framework for system-wide quality improvement in areas including training staff in current best practices, identifying at-risk individuals through comprehensive screening and assessment, and engaging at-risk patients with effective care management, evidence-based treatments, and safe care transition.

According to the Zero Suicide website, “The foundational belief of Zero Suicide is that suicide deaths for individuals under the care of health and behavioral health systems are preventable. Zero Suicide is based on the realization that people experiencing suicidal thoughts and urges often fall through the cracks in a sometimes fragmented and distracted healthcare system. Studies have shown the vast majority of people who died by suicide saw a healthcare provider in the year prior to their deaths. There is an opportunity for healthcare systems to make a real difference by transforming how patients are screened and the care they receive.”

READ more about the Zero Suicide Model in Tompkins County

At its inaugural meeting, Lincoln briefed the Steering Committee on suicide data, noting that suicide is the second leading cause of death among Americans aged 10-34. Lincoln outlined initial steps to be taken by participating organizations, such as forming Zero Suicide implementation teams and conducting the organizational self study assessing their current state of suicide care.

“I am here because I am passionate about preventing the unnecessary losses of community members, friends, and family to suicide,” Lincoln said. “I believe this group is going to be a powerhouse for change and action across our county. We can all do our own actions and work on our own approaches in our organizations, but I really think the best work is going to come when we come together and work collegially.”

Speaking at the July roundtable, Harmony Ayers-Friedlander, deputy commissioner of Tompkins County Mental Health Services, said:

“Your presence here today serves as a reminder of just how important this work is. Zero Suicide works. Because it gives us hope that we can make a difference, direction through a systems-based framework when faced with the complexity of human suffering, and real tools that help us at each step of the way.”

Organizations agreeing to participate in the Steering Committee are:

Tompkins County Health Department

Cayuga Health

Guthrie Cortland Medical Center

Northeast Pediatrics & Adolescent Medicine

Family & Children’s Service of Ithaca

MindWell LLC

Alcohol & Drug Council of Tompkins County

Cayuga Addiction and Recovery Services (CARS)

The Reach Project, Inc.

Cornell Health, Cornell University

Center for Counseling and Psychological Services, Ithaca College

Health and Wellness Services, Tompkins Cortland Community College

Suicide Prevention & Crisis Service

U.S. Department of Veterans Affairs

If you or someone you know feels the need to speak with a mental health professional, you can call or text the 988 Suicide and Crisis Lifeline at 9-8-8, or contact the Crisis Text Line by texting HOME to 741-741.

New Step Toward “Zero Suicide” in Tompkins County

Top healthcare leaders in Tompkins County have agreed to form a steering committee to drive local implementation of the Zero Suicide Model, an emerging standard designed to save lives by closing gaps in the suicide care offered by and across healthcare providers.

Zero Suicide roundtable participants, July 20

The move came during “Zero Suicide Roundtable: A Discussion on Best Practices in Suicide Prevention with Tompkins County Healthcare Leaders,” hosted on July 20 at the Statler Hotel by The Sophie Fund and Tompkins County Mental Health Services.

The two-hour roundtable was moderated by Jenna Heise, director of Suicide Prevention Implementation at the Office of Mental Health’s Suicide Prevention Center of New York.

The 13 roundtable participants represented Cayuga Medical Center, Guthrie Cortland Medical Center, Tompkins County Health Department, Tompkins County Mental Health Services, Family & Children’s Service of Ithaca, Suicide Prevention & Crisis Service, Cornell University, Tompkins Cortland Community College, and The Sophie Fund.

The leaders’ agreement is a step toward fulfilling Goal 2 of the Tompkins County Suicide Prevention Coalition’s 2022-2025 Strategic Plan, adopted last February, which calls for “quality improvement for suicide care in all Tompkins County healthcare and behavioral health settings.”

The strategic plan’s Objective 2.3 calls for the formation of a “Zero Suicide Work Group comprised of leading health and mental health providers to share ideas, experiences, and challenges, and lead collaborative, sustainable efforts to implement the Zero Suicide Model throughout Tompkins County.”

Harmony Ayers-Friedlander, deputy commissioner of Tompkins County Mental Health Services, introduced Heise to the gathering “as we renew our commitment to the implementation of the Zero Suicide Model in our community, within, and across, our healthcare settings.” She noted that the county’s Suicide Prevention Coalition was launched exactly five years earlier with the vision of “a community where no lives are lost to suicide.”

Addressing the healthcare leaders, Ayers-Friedlander added:

“Your presence here today serves as a reminder of just how important this work is. Zero Suicide works. Because it gives us hope that we can make a difference, direction through a systems-based framework when faced with the complexity of human suffering, and real tools that help us at each step of the way. Today is a time to evaluate where we are individually as institutions and collectively as a community in preventing suicide through this model.”

Jenna Heise, director of New York State’s Suicide Prevention Implementation, moderates a Zero Suicide leadership roundtable

Heise opened the roundtable with a brief overview of the Zero Suicide Model and then walked participants through a discussion on the model’s seven elements: leadership, training, screening and assessment, care planning, treatment, transition of care, and quality improvement.

“The foundational belief of Zero Suicide is that individuals in our care, on our watch, need not die by suicide, and that suicide is actually preventable for those in care,” Heise said. “The way that happens is that suicide prevention and suicide care become a core priority for health and behavioral health. We have not done a good job of that, frankly.”

“We need to have that leadership commitment,” Heise said. Under the model, she explained, a leadership commitment creates a “just culture” for suicide care that relies on systemic use of best practices rather than leaving suicide prevention to individual health workers.

“It has to be looked at as a systems problem,” she said. “For too long, we have left it to the crisis team or to one outstanding individual clinician or social worker, and our systems, or the newest person, the greenest person straight out of school, who had no schooling in suicide.”

Citing examples of successful implementation of Zero Suicide, such as in the Henry Ford Health System in Michigan, Heise added: “It is an aspirational goal but it is quite attainable. There are folks that have done this work and committed to it, and followed this framework in implementing the seven elements, and they have shown that you could significantly reduce the suicides, by rate and number, within your healthcare organization.”

Heise commended Tompkins County’s approach to creating a “safer suicide community, wrapped around health and behavioral healthcare, including partners on board like the health department, behavioral health, large health systems, universities, higher ed, and so forth. That’s where you start to really see impact, everybody speaking the same language, using the same tools, the same best practices, the same framework. This is very exciting.”

Participants shared their experiences with various aspects of suicide prevention measures within their systems. They noted the importance of cross-system coordination and integration for suicide care, the challenge of staffing, and a desire for greater suicide-specific training. Several participants noted their continuous quality improvement efforts in suicide care but said they did not follow the Zero Suicide Model per se.

The Sophie Fund provided participants with a packet of materials about the Zero Suicide Model and previous suicide prevention efforts that have been undertaken in Tompkins County. The packet included the following items:

Zero Suicide Organizational Self-Study

Transforming Systems for Safer Care

Quick Start Guide to Getting Started with Zero Suicide

“Vital Signs: Suicide rising across the US,” Centers for Disease Control and Prevention

“Changes in Suicide Rates United States, 2018–2019,” MMWR, Centers for Disease Control and Prevention

Sentinel Event Alert Issue 56: Detecting and treating suicide ideation in all settings, The Joint Commission

National Patient Safety Goal for suicide prevention, The Joint Commission

Three-Year Strategic Plan 2022-2025, Tompkins County Suicide Prevention Coalition

Resolution 2018-155, Suicide Prevention Coalition Zero Suicide Initiative, Tompkins County Legislature

The Watershed Declaration

Mental Health Support and Crisis Services Tompkins County, The Sophie Fund

“Health Care Contacts in the Year Before Suicide Death,” Journal of General Internal Medicine, by Brian K. Ahmedani, et al.

“Suicide Prevention: An Emerging Priority For Health Care,” Health Affairs, by Michael F. Hogan and Julie Goldstein Grumet

The roundtable was the fifth and final session of a Zero Suicide initiative launched by The Sophie Fund last November. Previous events included:

 “Call to Action: Suicide Prevention in Healthcare,” an expert briefing on the Zero Suicide Model for Tompkins County healthcare leaders, on November 16 by Jenna Heise, Director of Suicide Prevention Implementation at the Suicide Prevention Center of New York.

“Understanding, Identifying, and Addressing Suicide Risk: A Clinical Primer for Behavioral Health Providers,” on March 9 by The Wellness Institute

“Implementation of Zero Suicide,” a suicide prevention presentation for front line managers, on March 24 by Tammy Weppelman, State Suicide Prevention Coordinator at the Texas Health and Human Services Commission.

“Zero Suicide: Best Practices for Primary Care,” on June 16 by Virna Little, Co-Founder and CEO of Concert Health.

If you or someone you know feels the need to speak with a mental health professional, you can call or text the 988 Suicide and Crisis Lifeline at 9-8-8, or contact the Crisis Text Line by texting HOME to 741-741.

State-Local Partnership in Suicide Prevention

The Sophie Fund on Thursday applauded New York Governor Andrew M. Cuomo’s 2019 “Justice Agenda” for including a proposal to strengthen suicide prevention infrastructure through state and local partnerships.

stateofstatecuomo

“While there is much still to be done, we truly thank Governor Cuomo for his commitment to preventing suicide in our state and for taking concrete actions in order to do so,” said Scott MacLeod, a co-founder of The Sophie Fund. “The governor understands the importance of addressing this challenge at the community level and with results-oriented strategies.”

In his annual State of the State Book accompanying an address to the legislature on Tuesday, Cuomo called on New York State agencies to partner with communities in five critical areas of suicide prevention: innovative public health approaches; healthcare systems; cultural competence in prevention programming; comprehensive crisis care; and surveillance data. Under the proposal, communities that demonstrably strengthen suicide prevention infrastructure will receive a New York State designation.

MacLeod noted that recent progress in Tompkins County’s suicide prevention efforts stemmed in part from the vital support provided by the state Suicide Prevention Office and affiliated Suicide Prevention Center of New York. In July 2018, the Tompkins County Legislature unanimously passed a resolution to support the Zero Suicide Model, a pillar of the state’s comprehensive suicide prevention policy. The resolution called on local healthcare and behavioral healthcare providers to follow the model’s systematic clinical approach to preventing suicides.

The legislative act came a month after the newly formed Tompkins County Suicide Prevention Coalition voted overwhelmingly to recommend the Zero Suicide Model for healthcare providers as a countywide suicide prevention initiative.

“The state Suicide Prevention Office and Suicide Prevention Center of New York have been essential partners in the formation of the Tompkins County Suicide Prevention Coalition and in assisting local stakeholders with significantly expanding suicide prevention efforts,” said MacLeod. “We welcome the opportunity under Governor Cuomo’s proposal to expand our partnership with the state.”

Cuomo’s proposal builds on the work of the New York State Suicide Prevention Task Force formed at his direction in 2017. Cuomo charged the task force with identifying gaps in programs, services, and policies while simultaneously making recommendations to facilitate greater access, awareness, collaboration, and support of effective suicide prevention activities.

According to “Justice Agenda,” the 2019 State of the State Book:

“Suicide is an enormous public health problem. Suicide is the 10th leading cause of death in the United States. According to the Centers for Disease Control, from 1999 to 2016, suicide rates in New York State rose by nearly 30 percent, while other leading causes of death such as cancer, heart disease, and motor vehicle accidents all decreased. Each year nearly 1,700 New Yorkers die by suicide.”

In 2016, the state Suicide Prevention Office released “1,700 Too Many: New York State’s Suicide Prevention Plan 2016–17.” It focused on three main areas for battling the rising suicide rate: prevention in Health and Behavioral Healthcare Settings (Zero Suicide Model); Prevention in Competent, Caring Communities Across the Lifespan; and Suicide Surveillance and Data-Informed Suicide Prevention.