Healthcare expert Virna Little highlights a paradox in suicide prevention. Most primary care providers believe that suicide prevention is part of their role, she says. Yet, she adds, most of them also lack training during their education or professional experience in how to prevent suicide deaths among their patients.
Little was the featured presenter on June 16 at “Zero Suicide: Best Practices for Primary Care,” an event hosted via Zoom by The Sophie Fund and attended by Tompkins County physicians and their practices.
Her presentation walked attendees through a series of Zero Suicide protocols, including screening patients for suicide risk, assessing at-risk patients to determine appropriate levels of onward referrals, and developing safety plans to keep patients from acting on suicidal urges.
Little is internationally recognized for her work on integrating primary care and behavioral health, developing sustainable integrated delivery systems, and suicide prevention. She is the chief operating officer and co-founder of Concert Health, a national organization providing behavioral health services to primary care providers. She has conducted Zero Suicide trainings for more than 3,000 primary care providers in 27 states, and has spoken at the White House on national suicide prevention strategies.
The Zero Suicide Model is a set of strategies and tools for suicide prevention in healthcare as well as behavioral health care systems. It holds that by closing gaps in care through quality improvement measures, suicide deaths for patients in health and behavioral health systems are preventable. It is endorsed by the U.S. surgeon general and the State of New York’s Office of Mental Health. It is also advocated by the Tompkins County Suicide Prevention Coalition, whose 2022-2025 strategic plan identifies implementing Zero Suicide in healthcare across the county as one of its five goals.
Little stressed that primary care settings can “really move the needle” in reducing suicides. About 46,000 Americans take their own lives each year. Suicide is the 10th leading cause of death in the United States, and the second leading cause for people between 10-34.
Little urged primary care practices to operate a care system for treating patients at risk for suicide just as they do for patients with other chronic illnesses such as diabetes or asthma. She cited data showing that most people who died by suicide had a primary care visit within a month of their death. She noted that healthcare regulatory bodies, such as The Joint Commission, are saying “Listen, you really have to think about how you care for your patients at risk for suicide.”
DOWNLOAD: Primary Care Toolkit for Suicide Prevention
Little started by explaining the need for everyone on a practice’s care team to be aware of patients who are assessed as being at risk of suicide.
She related the story of a young woman who died by suicide after phoning her doctor’s office to cancel three appointments. The staff member who took the calls was unaware that the patient had been flagged as a suicide risk so took no steps to raise an alarm about the cancellations.
Little said that providers often tell her that they don’t know what to do if a patient shares that they are thinking of suicide.
“There’s one thing that is really the most helpful for people, and anyone can do it regardless of your background, your discipline, how long you’ve been in the practice,” she said. “That’s to give someone hope. We can all give someone hope.”
“It could very well be the first time that they’ve talked about suicide, or ever told anyone that they were thinking about suicide,” she said. “And so we want to make sure that our initial response is something that is going to be incredibly helpful for people, and to make sure that they know this is a safe place.”
Not to be caught off guard or utter an inappropriate message, she advises providers to create their own “storage statements”—words they can quickly use to show a suicidal patient that their life matters and to give them hope.
“Thank you for telling me.”
“You’re really important to us here at the center.”
“Your life is really important to me. Your life matters to me.”
“I have hope for you. I can see how strong you are.”
DOWNLOAD: Mental Health Support and Crisis Services in Tompkins County
Little said she was sympathetic to providers who feel that they don’t have enough time with individual patients to address the complexity of someone presenting with a risk of suicide. But she argued that providers have to think about implementing the same system of care for suicide as they do for other chronic illnesses. For example, she said, that may mean moving on to the next patient but coming back later to speak with the suicidal patient again.
“It would be a beautiful day in primary care if people came in for just one thing, or they came in for what turned out to be the most important, or life threatening thing.”
Little shared a personal story of how her husband went to his doctor complaining about hearing loss. The provider routinely took his height, weight, temperature, and blood pressure, and then informed him, “Listen, I’m really concerned, your pressure is incredibly high. I’m, not sure you’re going to be able to go home.” Little said the visit turned into one completely focused on blood pressure rather than hearing loss.
For patients at risk of suicide, she said, “We do the same things. We stop. We get information. We ask some questions. And we figure out an alternate level of care if we need one, or an appropriate level of care. That’s the way to start to think about patients who are at risk for suicide.”
Little observed that providers often administer the Patient Health Questionnaire (PHQ-9), a screening tool for depression. Little said that providers are recommended to use additional evidence-based, suicide-specific tools that provide indications of suicide plans, methods, and intent: the Columbia-Suicide Severity Rating Scale (C-SSRS) and the Ask Suicide-Screening Questions (ASQ) tool.
She noted that there is a spectrum of suicidality, and that it is important to refer patients to appropriate levels of care. She cautioned against automatic referrals to emergency departments, saying that this can in some cases exacerbate a patient’s mental health condition.
“I worked for 17 years in the Putnum Hospital emergency room in New York State,” she said. “There is no magic that happens there. Most people I actually did not admit because that was not the level of care that they needed. So we really want to think about assessing risk, which can and does happen every single day in primary care settings, and can happen for suicide just like it does for other chronic illnesses.”
Little highlighted the importance of developing safety plans for patients, likening them to the “stop, drop, and roll” drill that children learn about what steps to take if their clothes ever catch fire.
“The likelihood that we’re going catch on physical fire is not very high, but we all know what to do,” she said. “So I want you to know what to do in case you catch on emotional fire.”
She said the safety plan should include providing the at-risk individual with the number of the National Suicide Prevention Lifeline—988 or (800) 253-8255—and actually having them put the number in their phone on the spot. Little’s presentation cited the Stanley-Brown Safety Planning Intervention, in which providers work with patients to develop a six-part safety plan that lists the individual’s internal coping strategies, distraction strategies, people and professionals they can contact in a crisis, and lethal means restriction strategies.
Little explained that discussing restricted access to lethal means with their patients is a critical piece of the safety plan. For people at risk of suicide, keeping guns out of harms way, or having a pharmacy issue prescription medications in individual pill packs, can really save lives, she said.
Little said she also directs at-risk patients to tools such as the Now Matters Now website, which includes videos with real people explaining the skills they’ve learned for coping with suicidal thoughts.
Little said once the appointment is over, caring contacts are “incredibly helpful” for people. She said providers should send a text or an email saying “Really glad we had a chance to see you today, I’m looking forward to seeing you next week.”
Little recalled being approached by one of her patients at a grocery store. “This woman came up to me, she pulled my note out of her purse, and said, ‘Virna, I carry this with me. It’s helpful.’ Just knowing that somebody out there cared gave her hope. Don’t underestimate the value of giving somebody hope.”
In conclusion, Little stressed the need for primary care providers to manage patients at risk for suicide like they would those with other chronic illnesses.
“If I am having asthma, and I come into your practice, what do you do? You might give me a treatment. you would ask me questions about my medication in my history. You would ask me about environmental triggers. You would ask me about emotional triggers. You might give me some education around how to use a rescue inhaler. You might make a referral to someone to come out to my home, or to a pulmonologist. You might do an asthma action plan. And so, when you think about all of those steps that you would do, you do that routinely for lots of chronic illnesses. All of that would be incredibly applicable to someone who was at risk for suicide.”
Little’s event was the fourth in a series of five presentations and trainings on Zero Suicide that The Sophie Fund is providing to the Tompkins County healthcare community. In July, along with the Tompkins County Mental Health Services, The Sophie Fund will co-host “Zero Suicide Roundtable: A Discussion on Best Practices in Suicide Prevention with Tompkins County Healthcare Leaders.”
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 988 or 1-800-273-8255, or contact the Crisis Text Line by texting HOME to 741-741.
READ MORE: Suicide Prevention in Tompkins County