A bold new way of talking about suicide prevention is sweeping the suicide prevention landscape. Health and mental health care systems are aiming to reduce the number of suicides by people receiving their care to zero. Not cut rates by half. Not by a quarter. Eliminate the ways for people to fall through the cracks in those systems.
Zero Suicide is a huge aspiration and an audacious goal — a big, hairy, audacious goal, or BHAG — as national suicide prevention leader David Covington pointed out at the recent “Be the Connect: Intro to Zero Suicide” conference in Burien, Wash. Across the state in Spokane, more than 400 participants gathered for Zero Suicide Inland Northwest’s second annual conference and training day, Tools for Preventing Suicide March 11 at Gonzaga University.
Like the free climbers who ascended El Capitan’s Dawn Wall in Yosemite, accomplishing something no one thought possible, Covington said, the idea of Zero Suicide is ascending the wall of suicide.
Scaling the wall
For some idea of the size of that wall: Suicides have risen to more than 40,000 a year, with 30 percent to 80 percent of those people accessing health care within a year of their deaths, according to a research funding announcement for Zero Suicide from the National Institute for Mental Health. The NIMH outgoing director last fall cited the escalating suicide rate as a failure on his watch. About a quarter of those who die by suicide are treated for psychiatric issues.
Zero Suicide challenges health care systems “to relentlessly pursue a reduction in suicide and improve the care for those who seek help.” Its approach is “based on the realization that suicidal individuals often fall through multiple cracks in a fragmented and sometimes distracted health care system, and on the premise that a systematic approach to quality improvement is necessary.”
Despite the immensity of the problem, aiming for zero suicides is key, says Thomas Priselac, CEO of Cedars Sinai Medical Center: “It is critically important to design for zero even when it may not be theoretically possible. When you design for zero, you surface different ideas and approaches that if you’re only designing for 90 percent may not materialize. It’s about purposefully aiming for a higher level of performance.”
Zero Suicide’s roots trace to health systems that made systematic changes to dramatically lower their suicide risk, including the U.S. Air Force and the Henry Ford Health System in Detroit. At Henry Ford, the suicide rate for those being treated for a mental health problem or substance abuse was zero per 100,000 in 2009. “It’s crept up to 20 per 100,000 per year, but that’s still 80 percent lower than it was when the program began,” epidemiologist Brian Ahmedani told NPR.
Many groups claim Zero Suicide as a project, a priority or a program. That is one of its greatest strengths, just as the collaboration behind the recent event in Burien signals its importance to a wide range of systems — and people.
To Peter Schmidt, director of the Behavioral Health Program of the Washington Department of Veterans Affairs, who attended the recent conference in Burien, Zero Suicide is about “helping everyone understand that suicide is not an individual issue, it’s a societal issue…. It’s about raising our social awareness about how to learn about the topic as much as we can and to provide support and interventions where appropriate.”
The particulars are complex, but all trace to major shifts toward more systematic thinking and treatment. Seven Zero Suicide Toolkit elements were emphasized in the Burien conference: Lead, train, identify, engage, treat, transitions and improve.
Lead stands for a change in culture around suicide care that starts with top leadership in a hospital or health care system.
Train means that every employee in the health care system receives up-to-date training on suicide prevention and how the system of Zero Suicide care works.
Identify emphasizes early identification of suicide risk, through visits with primary care doctors and other routine health care opportunities.
Engage means actively involving the patient as a partner in making decisions about her own treatment plan.
Treat means addressing suicidality itself, which most often requires on-going treatment as the patient learns how to head off his suicidal thinking.
Transitions call for seamless care and follow-through from one phase treatment to the next.
Finally, improve refers to the need for ongoing learning and progress inside a health care system.
These are powerful moves for any system to make — and the results, as the Henry Ford program has shown — are equally powerful.
Forefront Co-founder Jenn Stuber challenged the Burien conference attendees ”to be the ones who connect to make the systems changes happen … at a state level.” She said, “We need to be talking with other systems, such as schools, colleges and other systems like criminal justice systems. We need to raise the salience of suicide wherever we go.”