Zero Suicide in Healthcare

Zero Suicide, David W. Covington, Behavioral Health Version 3.0, Recovery“Over the decades, individual [mental health] clinicians have made heroic efforts to save lives… but systems of care have done very little.” With this quote from SAMHSA’s Suicide Prevention Bureau Chief Richard McKeon, we launched our two-day kick-off meeting of the new Zero Suicide in Healthcare Advisory Board last week in Baltimore, Maryland.

Nearly 20 years ago, I received a phone call that I was unprepared for. I had just returned home after having completed the National Counselor Exam. I fancied myself a “master” counselor, since I was to graduate later in the week. However, my confidence and belief in myself evaporated, for as soon as I walked in the house, I received a call from a 50-year old parishioner outreaching someone/anyone from his church to say goodbye, for he had a shotgun and was intending to end his life by suicide that night.

My first thought was not fear, wondering what to do and how to help (that came second). It was ”You’ve got to be kidding me. Really?!” I had just — just —  finished a 60-hour Community Agency Counseling master’s program over the last four years, complete with video tapes of my work, internships and practicums, and I did not receive a shred of preparation for this moment, not five minutes. “The system” did not see suicide care as relevant, and as a result, I was on my own to know what to do.

It was the next morning before I returned home, having muddled through how best to help. The bad – law enforcement chided me when I ultimately talked the individual into meeting me in the McDonald’s in the back of a Wal-Mart in rural Tennessee (the guy with the shotgun). The okay – I built rapport, engaged and we collaborated together. The good – a psychiatrist sent me to the man’s home to remove the shotgun with an eye to means reduction for safety planning.

A year later, I started my first job in community mental health, and our clinic was never far from the issue of death and suicide. Many of the individuals we served in the rural clinic were diagnosed with Severe and Persistent Mental Illness. Years later, I would learn that those with Schizophrenia, Bipolar Disorder, Major Depressive Disorder, Borderline Personality Disorder and Anorexia Nervosa possess suicide rates 10 to 15 times greater than the general population. Once again, my organization did not prepare me to assess or treat these individuals, and they provided little support other than access to psychiatrist orders for involuntary inpatient care. We (and those at risk) were largely on our own.

Over the past five years, we have surveyed more than 30,000 in the behavioral healthcare workforce across nine states, and asked clinicians, case managers, peer specialists, and other community behavioral health center staff to rate their own skills, training, and supports to effectively engage those at risk of suicide. On average, there is about a coin-toss chance that they will at least “agree” that they have what is needed. About one in four report that someone under their care and responsibility has died by suicide (and for almost half that group, this tragedy has occurred more than once).

It’s not that agencies delivering behavioral healthcare services don’t believe that suicide is part of their responsibility; they just don’t think about how little focus and systematic support they actually provide. In 2010, Forbes put it more strongly in “The Forgotten Patients” that fear, logistics, and high risk “make suicide the neglected disease.” Suicide care is actually peripheral for most behavioral healthcare leaders when you examine the approach their companies deliver on a day to day basis.

As a nation, our core healthcare systems have dabbled in suicide prevention. Neither Medicare, Medicaid, state authorities, nor health plans routinely report suicide deaths as a core key quality performance indicator. “The National Institutes of Health is spending a paltry $40 million in 2010 studying suicide, versus $3.1 billion for research on AIDS, which kills half the number of Americans. (Another government agency spends $48 million on hotlines and prevention)” (Forbes, 2010).

Last year, the revised National Strategy for Suicide Prevention included a goal to establish suicide prevention as a core responsibility of health systems. Our Zero Suicide Advisory Board has set out to make suicide care the bull’s eye, not an obligatory afterthought. One of our members, Paul Schyve, of Joint Commission has called this shift in focus a “burning platform,” as we now understand that suicide is imminently preventable and that systems are powerful in a way we did not even a decade ago.

In 1975, the Golden Gate Bridge was nearing its 500th suicide death, and the community was distressed; something should be done. Although a barrier was considered, nothing came of it. Of the three reasons offered, cost and aesthetics were only numbers 2 and 3. The primary reason: most did not believe those “truly” intent on suicide could be stopped. It seemed an exercise in futility. This pernicious myth continues to have deep roots in the medical and behavioral communities. It underlies our fear as systems leaders, and disables us from addressing this most challenging and complex problem.

This fatalistic view just doesn’t match the science, nor the increasingly rich voices of those who have lived with and attempted, but survived, serious suicide attempts. In the documentary “The Bridge,” Kevin Hines talks about his last five seconds in 2000. In one fatal second, he leaps over the 3½ foot rail of the iconic bridge in a bid to end his pain. In the very next second of the four-second fall, he realized he would do anything to be back on the bridge with his hands firmly gripping the steel rail.

Intense ambivalence (what Europeans have called “personal indecision”) seems a universal part of human existence with suicide. Despite enormous psychic pain, our bodies and minds fight to survive until the end, a trait that Dr. Thomas Joiner has said abides deep “within our cells and within our souls.” This was made painfully aware to me when I learned about a woman who police say died by suicide; however, the grieving family insists she was murdered, because she was found hanging with her feet tied and her hands bound behind her back.

Tragically, even alone, suicidal individuals often realize how difficult it is to end their lives because they themselves fight back. Their bodies don’t cooperate and their minds are wired for self-preservation. When we as individuals add our help, we save lives. And, we know today that diagnosis is not destiny: 19 of 20 survivors we save go on to live out their natural lives.

What if healthcare leaders focused on suicide care like they have hospital-acquired infections, wrong-site and wrong-patient surgery, medication errors, and patient falls? What if systems of healthcare devoted their enterprise resources, performance improvement, manualized protocols, automated software systems, and data tracking to suicide?

In 2001, the Henry Ford Health System in Detroit, Michigan initiated its Perfect Depression Care program and suicide deaths were reduced 75% in the first four years (inspiring parallels to an earlier leadership and culture change initiative in the US Air Force, which produced similar results). In 2010, I met Don Berwick, then-CMS Director and author of “Crossing the Quality Chasm.” I asked him if he was aware of the impact his direction had made with suicide care at Henry Ford. “Yes, absolutely,” he replied, and without transition, he immediately began telling the story of reducing infections in hospitals through the Institute for Healthcare Improvement. In healthcare, we use our systems to attack complex problems every day. For Berwick, suicide was no different.

In 2009, innovative partners across ten states began coming together to develop a framework for Zero Suicide in Healthcare. The National Council for Behavioral Health called it “Not Another Life to Lose,” leaders in Texas have named it “Suicide Safer Care Centers,” and New York’s Institute for Family Health has labeled it “the Power of Zero.” The elements are the same: top leadership commitment, workforce assessment and training, universal screening, standardized assessment, and clinical pathways to care, including a collaborative safety plan, and access to evidence-informed treatment for suicidality and mental illness.

In 2013, there are a growing number of demonstration models to showcase suicide care as core business, including one of the largest Community Mental Health Center systems in the country, Centerstone America. Virna Little, Senior VP with the Institute for Healthcare Improvement, shared with our Zero Suicide Advisory Board an in-depth look at how her nearly 30 integrated Federally Qualified Health Center sites have hotwired their EHMR Epic to protocolize suicide intervention and care (YouTube playlist).

I have had the privilege of co-leading this effort with Mike Hogan, who has headed up statewide programs for more than 30 years. In the past, Mike has said, “Suicide represents a worst case failure in mental health care. We must work to make it a ‘never event’ in our programs and systems of care.” Following Virna’s presentation, he noted, “This moves in the direction of a standard of care approach… It would not be responsible not to provide care and support based on the current state of knowledge.”

Today, healthcare systems are beginning to address suicide as they have other illnesses and safety issues (like reducing seclusion and restraint in inpatient units); to take suicide out of the shadows and bring it into the light, making it part of their measurements of success or failure. Treating suicide can no longer be a single-person approach; it must be a team effort with systems leading the way in education, measurement, support and care. These efforts in healthcare will go a long way to making this a nation free from the tragedy of suicide.

*Note: David Covington is a member of the National Action Alliance for Suicide Prevention executive committee and Vice-Chair of the National Suicide Prevention Lifeline Steering Committee. Organizations interested in learning more should visit Special recognition to SAMHSA, the Suicide Prevention Resource Center, and Universal Health Systems for their support and partnership. 

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