Zero Suicide

The Zero Suicide Model, sometimes called the “Suicide Safer Care Model,” is a set of strategies and tools for suicide prevention in health and behavioral health care systems.

VIDEO: The Zero Suicide Healthcare Call to Action

Zero Suicide argues that suicides can be prevented by closing cracks in healthcare systems—that “suicide deaths for individuals under care within health and behavioral health systems are preventable.”

Zero Suicide means making suicide prevention a core responsibility of healthcare. Specifically, this entails a systematic clinical approach in healthcare systems—training staff, screening for suicide ideation, utilizing evidence-based interventions, mandating continuous quality improvement, treating suicidality as a presenting problem—and not simply relying on the heroic efforts of crisis staff and individual clinicians.

VIDEO: Michael Hogan, “Zero Suicide in Health Care”

As its developers put it, “Zero Suicide models what it takes to make a system-wide, organizational commitment to safer suicide care. 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 health care system. Studies have shown the vast majority of people who died by suicide saw a health care provider in the year prior to their deaths. There is an opportunity for health care systems to make a real difference by transforming how patients are screened and the care they receive.”

Zero Suicide is at the heart of the 2012 National Strategy for Suicide Prevention, released by the U.S. Surgeon General and the National Action Alliance for Suicide Prevention. The NSSP’s Goal 8 is to “promote suicide prevention as a core component of healthcare services.” Goal 9 is to “promote and implement effective clinical and professional practices for assessing and treating those at risk for suicidal behaviors.”

According to the developers, a “Zero-based” mindset in healthcare happens by routinely and consistently embedding evidence-based practices focused on patient safety and offer hope and recovery for people at risk for suicide. “Zero Suicide dismisses the general fatalism about making a dent in the outcomes for those at risk for suicide that persists in health care,” states the Zero Suicide website. ”The Zero Suicide model represents a galvanizing but feasible approach for identifying and caring for people at risk for suicide. Asking directly about suicide and responding appropriately should and could be as routine as having blood pressure, height and weight checked at every health care visit, yet this normalization has been mostly resisted to date.”

VIDEO: Michael Hogan, “Zero Suicide in Health and Behavioral Health Care”

Zero Suicide is explicitly embraced by New York State’s Suicide Prevention Plan 2016–17, entitled 1,700 Too Many. Implementing Zero Suicide in health and behavioral healthcare settings is the first pillar of the suicide prevention strategy outlined in the plan. The second pillar is to “create and strengthen suicide safer communities.”

Zero Suicide has been adopted and adapted for use in health and behavioral health care systems such as hospitals, primary care, emergency departments, outpatient mental health, inpatient psychiatry, substance misuse care settings, children’s hospitals, crisis care, corrections, foster care systems, federal, state, and local agencies, Indian Country, health plans and payers, colleges and universities, and technology companies, according to the Zero Suicide website.

To assist healthcare organizations in implementing the seven fundamentals of Zero Suicide, SPRC established the Zero Suicide project offering online resources such as an organizational self-study, implementation toolkits, readings, and webinars, and an offline Zero Suicide Academy providing two-day trainings for healthcare leadership.

The Suicide Prevention Center of New York State highlights a variety of evidence-based trainings, workshops, online learning modules, and resources available in New York for state employees, clinicians, other health care workers, community members, and school staff.

The Tompkins County Legislature on July 17, 2018 unanimously passed a resolution to support the Zero Suicide Model, calling on local healthcare and behavioral healthcare providers to follow the model’s systematic clinical approach to preventing suicides. A month earlier, the Zero Suicide Model was adopted by the Tompkins County Suicide Prevention Coalition.

Seven healthcare providers in Tompkins County stepped up to be “Zero Suicide Champions” in June 2018:

Video Presentations

Watch the videos featuring presentations on the Zero Suicide Model by Michael Hogan, a developer of the model, who served as New York State Mental Health Commissioner (2007–2012), Ohio Department of Mental Health Director (1991–2007) and Connecticut Mental Health Commissioner (1987–1991).

Michael Hogan, “Zero Suicide in Health Care” (2014) [VIEW VIDEO]

Michael Hogan, “Zero Suicide in Health and Behavioral Health Care” (2015) [VIEW VIDEO]

Zero Suicide Resources

Suicide Prevention Resource Center

Zero Suicide Model

2012 National Strategy for Suicide Prevention

The Surgeon General’s Call to Action to Implement the National Strategy for Suicide Prevention

1,700 Too Many: New York State’s Suicide Prevention Plan 2016–17

Zero Suicide Model in Tompkins County

Our Goal: Zero Suicide for Tompkins County

“Report on the Zero Suicide Model In Tompkins County,” The Sophie Fund  (March 26, 2018)

Tompkins Coalition: “Yes” to Zero Suicide Model

Tompkins County Adopts the Zero Suicide Model

Zero Suicide Roadmap

(Source: https://zerosuicide.edc.org/)

Zero Suicide is based on the following foundational principles:

Core Values—the belief and commitment that suicide can be eliminated in a population under care by improving service access and quality and through practicing continuous quality improvement.

Systems Management—taking systematic steps across systems of care to create a culture that no longer finds suicide acceptable, setting aggressive but achievable goals to eliminate suicide attempts and deaths, and organizing service delivery and support accordingly.

Evidence-Based Clinical Care Practices—adopting practices that research shows reduce suicide deaths and behaviors and that are delivered through the entire system of care and that emphasize productive patient-staff interactions.

The Zero Suicide Model operationalizes the core components necessary for health care systems to transform suicide care into seven elements:

LEAD—Lead system-wide culture change committed to reducing suicides.

TRAIN—Train a competent, confident, and caring workforce.

IDENTIFY—Identify individuals with suicide risk via comprehensive screening and assessment.

ENGAGE—Engage all individuals at-risk of suicide using a suicide care management plan.

TREAT—Treat suicidal thoughts and behaviors directly using evidence-based treatments.

TRANSITION—Transition individuals through care with warm hand-offs and supportive contacts.

IMPROVE—Improve policies and procedures through continuous quality improvement.

How Healthcare Providers Can Get Started

What is Zero Suicide?

Quick Guide to Getting Started with Zero Suicide

Zero Suicide Organizational Self-Study

Zero Suicide Work Plan Template

Workforce Survey

Data Elements Worksheet

Training Opportunities

Training and Courses to Support Zero Suicide Implementation

Suicide Care Trainings Options

Counseling on Access to Lethal Means

Preventing Suicide in Emergency Departments

For clinicians, other health care workers, community members, and school staff in New York State

Suggested Reading—Zero Suicide Model

“Zero Suicide: The Dogged Pursuit of Perfection in Health Care,” David W. Covington, LPC, MBA, Michael F. Hogan, PhD

“The Relationship Between Suicidal Behaviors and Zero Suicide Organizational Best Practices in Outpatient Mental Health Clinics” by Deborah M. Layman, et al.

“Efficacy of the Zero Suicide Framework” by Nicolas J.C. Stapelberg, Jerneja Sveticic, Ian Hughes, Alice Almeido-Crasto

“Inconvenient truths in suicide prevention: Why a Restorative Just Culture should be implemented alongside a Zero Suicide Framework” by Kathryn Turner, Nicolas Stapelberg, Jerneja Sveticic and Sidney Dekker

“Implementing a systems approach to suicide prevention in a mental health service using the Zero Suicide Framework” by Kathryn Turner, Jerneja Sveticic and Alice Almeida-Crasto

“Building a System of Perfect Depression Care in Behavioral Health” April 2007 C. Edward Coffey

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

“Challenges of Population-based Measurement of Suicide Prevention Activities Across Multiple Health Systems” by Bobbi Jo H. Yarborough, Brian K. Ahmedani, et al.

Compliance Standards Pave the Way for Reducing Suicide in Health Care Systems

“An Update on Perfect Depression Care” by C. Edward Coffey, M.D., M. Justin Coffey , M.D., and Brian K. Ahmedani , Ph.D.

“How We Dramatically Reduced Suicide” by M. Justin Coffey, MD & C. Edward Coffey, MD

“Perfect Depression Care Spread: The Traction of Zero Suicides” by M. Justin Coffey, MD

“Depression Care Effort Brings Dramatic Drop in Large HMO Population’s Suicide Rate” by Tracy Hampton

“Interview with Dr. Michael Hogan from the National Action Alliance for Suicide Prevention,” National Center for Integrated Behavioral Health

“Improving Care to Prevent Suicide Among People with Serious Mental Illness: Proceedings of a Workshop,” National Academies of Sciences, Engineering, and Medicine.

Suggested Reading—Training

(Source: https://zerosuicide.edc.org/)

“Preventing Suicide Through Improved Training in Suicide Risk Assessment and Care” Schmitz, W. M., Jr, Allen, M. H., Feldman, B. N., Gutin, N. J., Jahn, D. R., Kleespies, P. M., . . . Simpson, S. (2012)

“Training Mental Health Professionals to Assess and Manage Suicidal Behavior” Oordt, M. S., Jobes, D. A., Fonseca, V. P., & Schmidt, S. M. (2009)

“We tell suicidal people to go to therapy. So why are therapists rarely trained in suicide?” Alia E. Dastagir, USA TODAY

Suggested Reading—Diagnosis

(Source: https://zerosuicide.edc.org/)

Suicide Screening and Assessment

“Does Response on the PHQ-9 Depression Questionnaire Predict Subsequent Suicide Attempt or Suicide Death?” Simon , G. E., Rutter, C. M., Peterson, D., Oliver, M., Whiteside, U., Operskalski, B., & Ludman, E. J. (2013).

“Suicide Risk Assessment in Clinical Practice: Pragmatic Guidelines for Imperfect Assessments” Fowler , J. C. (2012).

“VA/DoD Clinical Practice Guideline for Assessment and Management of Patients at Risk for Suicide”

Suggested Reading—Patients

(Source: https://zerosuicide.edc.org/)

“Development of a Clinical Guide to Enhance Care for Suicidal Patients” Oordt, M. S., Jobes, D. A., Rudd, M. D., Fonseca, V. P., Runyan, C. N., Stea, J. B., . . .  Talcott, G. W. (2005).

“Ethical and Competent Care of Suicidal Patients” Jobes, D. A., Rudd, M. D., Overholser, J. C., & Joiner, T. E., Jr. (2008).

“Building a Therapeutic Alliance with the Suicidal Patient” K. Michel, & D. A. Jobes (Eds.). (2011).

“Safety Planning Intervention: A Brief Intervention to Mitigate Suicide” Stanley, B., & Brown, G. (2012).

Suggested Reading—Treatment

(Source: https://zerosuicide.edc.org/)

Beck Institute: Cognitive Behavior Therapy for Depression and Suicidality

The Linehan Institute: Behavioral Tech

Managing Suicide Risk Collaboratively: The CAMS Framework

Two-year Randomized Controlled Trial and Follow-up of DBT vs Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder

The Collaborative Assessment and Management of Suicidality (CAMS): An Evolving Evidence‐based Clinical Approach to Suicidal Risk

Evidence-Based Psychotherapies for Suicide Prevention: Future Directions

Suggested Reading—Continuity of Care

(Source: https://zerosuicide.edc.org/)

Best Practices in Care Transitions for Individuals with Suicide Risk: Inpatient Care to Outpatient Care

Continuity of Care for Suicide Prevention: The Role of Emergency Departments

“Can Postdischarge Follow-up Contacts Prevent Suicide and Suicidal Behavior? A Review of the Evidence” Luxton, D. D., June, J. D., & Comtois, K. A. (2013).