Abstract
‘. . . while suicide is a public health problem, many solutions involve systematic clinical approaches—like care for other chronic health problems.’
The thoughtful review of the state of suicide prevention (Robin Stone and Alex Crosby (pp. 404-420 of this issue) comes on the heels of Robin Williams’s suicide on August 11, 2014. Williams’s death was, first and foremost, a personal tragedy for him and his family. Sadly, this tragedy will be endured by more than 90 US families a day until we strengthen efforts to prevent suicide.
Suicide is the 10th leading cause of death in the United States. However, as Stone and Crosby report, the number of deaths is small compared with the almost 500 000 emergency department visits after intentional self-harm. The personal and economic impact is substantial: $55 billion in economic impact, almost 800 000 years of potential life lost annually, and many thousand individuals affected by loss.
The trend in the decade between the first National Strategy for Suicide Prevention 1 and the recent update of this plan 2 is revealing. In 2001, there were 30 622 deaths from suicide. 3 As of this writing, we do not yet know the number of suicide deaths for 2012, because (symptomatic of inadequate attention to the problem) reporting lags by about 3 years. For 2011, the latest data available, there were 39 518 suicide deaths. 4 A 29% increase in deaths in a decade does not indicate a public health or clinical success. To communicate that suicide prevention is a high priority, Healthy People 2020, the nation’s health goals, includes it among 26 leading health indicators. 5
Despite the high toll and official priority designation, resources (from research investments 6 to support for interventions) are strikingly limited, especially when so many solutions are suggested.
To reduce suicide’s toll, the United States needs to (a) increase suicide prevention research and innovation, (b) bring about greater uptake of successful practices, (c) realize more integration of public health and clinical care, and (d) sustain the increased attention on suicide prompted by Mr Williams’s death. To the latter point, calls to the National Suicide Prevention Lifeline (1-800-273-TALK) and other hotlines spiked to their highest levels ever the day after Williams’s death was reported. 7
Emerging evidence—some but not all mentioned in Stone and Crosby’s review—suggests that focused action by health professionals in clinical settings could save many thousands of lives. In short, while suicide is a public health problem, many solutions involve systematic clinical approaches—like care for other chronic health problems.
The field of suicide prevention is challenging for many reasons. The isolation that can both cause and result from suicidality is profound; it means it is hard to reach suicidal people, especially with population-based approaches. Research on suicide prevention is also difficult; although suicide is shockingly common, a death rate of about 13 per 100 000 makes it hard to find populations to study and the ethics and logistics of conducting controlled trials make it almost impossible. In the absence of simple solutions, the field is diffuse; the 2001 National Strategy had 11 goals and 68 objectives.
Our perspective, however, is that we have sufficient knowledge to guide actions that would save many thousands of lives. Much of this knowledge began to emerge in a project that Stone and Crosby mention, The Henry Ford Health System (HFHS) “Perfect Depression Program.” The program was developed within the behavioral health division at HFHS to try and achieve “zero defects” care for depression. Courageously, HFHS used as one measure of its effectiveness deaths by suicide. As Stone and Crosby note, This model relied on suicide assessment for all behavioral health patients . . . specific strategies included means restriction for patients, provider education, patient follow-up via phone calls, and patient peer support services. Between baseline and follow-up, a period of 11 years, suicides dropped by 82%.
The HFHS approach was a systematic clinical program that achieved striking results.
A significant feature of how HFHS measures suicide deaths makes the results even more significant: Suicide deaths are counted for any patient in the HFHS insurance plan, not just those receiving behavioral health care. The HFHS logic is that if the care system failed to identify the need for behavioral health and/or suicide care, it was an error.
Despite this impressive reduction in suicide, the HFHS results have received little attention from policy makers and researchers.
Could the HFHS results be achieved in other health systems? This question was examined by the Clinical Care Task Force of the Action Alliance for Suicide Prevention. The report of the task force 8 concluded that “suicide care” was now feasible. In recommending a focus on suicide prevention as a clinical activity, not simply a vague “public health” approach, the task force considered the many “cracks” in the health care system that suicidal patients slip through: as Stone and Crosby report, 45% of people who die by suicide saw a non–mental health provider in the 30 days before they died; 25% saw a mental health provider.
Our blunt interpretation is that suicidality is missed too often in primary care settings, and inadequately treated in behavioral health settings. The HFHS experience and other input led the Clinical Care Task Force to suggest that suicide care, with an audacious label and goal of “Zero Suicides” for patients involved in care, should be customary in health care settings. In the words of the new National Strategy for Suicide Prevention’s Goal 8: “Promote suicide prevention as a core component of health care services.” This is consistent with quality measures for suicide prevention.
The Zero Suicide care model has now been substantially “built out” (with background information and implementation resources at www.zerosuicide.com) and implemented successfully in leading behavioral health and advanced primary care centers. Five clinical activities—wrapped in organizational leadership and a just safety culture—are the “active ingredients” of Zero Suicide:
Screening and assessment. People receiving health care (and unquestionably all people with risk, e.g., any behavioral health condition, trauma history, or recent loss) should be asked about suicide.
Safety plans. Collaborative, 1-page plans 9 identify warning signs, coping strategies, and other concrete actions including steps to make the environment safe (lethal means restriction).
Means restriction (as Stone and Crosby note) is effective to reduce suicide.
Directly treating suicidality in community treatment (when this can be done safely) rather than an automatic, costly, and intrusive commitment to inpatient care is emerging as a best practice.
Supportive contacts. Brief and timely supportive contacts to suicidal people, especially between scheduled appointments or following missed appointments.
Conclusion
The scale of human suffering and economic burden caused by suicide warrants increased attention from the public and those who set priorities for health care, public health, and prevention research. As documented by Stone and Crosby, while large knowledge gaps remain, the field has identified practices and systems that are effective in preventing suicide. The knowledge gaps need to be filled and successful interventions used more widely. To achieve the Healthy People 2020 objective of reducing suicides by 10% and progress on related clinical quality measures, we must take these steps.