Working Toward Zero

Research has shown that nearly half of all people who die by suicide see a mental health professional in the 12 months before their death. And for years, mental health providers have been wondering how these visits can help to save more lives.

The National Action Alliance for Suicide Prevention (Action Alliance) is addressing this problem head on, with an effort whose title is as plain as its goal—Zero Suicide. The approach aims to improve the ability of health care systems to assess, treat, and follow up with people who may be at risk for suicide. And by calling it “Zero Suicide,” it sets an ambitious goal in the United States, where upwards of 38,000 people die by suicide each year.

“It’s a provocative title, but it has a purpose,” says EDC’s Julie Goldstein Grumet. “It isn’t reasonable to say, ‘it’s okay to aim for only 10.’”

Goldstein Grumet says that for a long time, mental health clinicians have treated suicide as a tragic but often unpreventable end for many clients who pass through their doors.

“Suicide simply wasn’t seen as a failure of the mental health system that had tried to care for them,” she says.

Zero Suicide in Health and Behavioral Health Care aims to change that perception. It calls upon clinicians, primary care doctors, nutritionists, and physical therapists—all staff within any setting with behavioral health services—to be more accountable for monitoring the mental health needs of clients.

“The adoption of a comprehensive set of standards, procedures, trainings, and policies by health care systems is groundbreaking,” says Goldstein Grumet. “It has the potential to significantly improve care and outcomes for individuals at risk of suicide. Clinicians will be better trained, leadership will be more supportive, and suicide risk will be part of regular mental health screenings.”

Nationally, a handful of sites are already implementing Zero Suicide, including Universal Health Services (UHS), one of the largest hospital management companies in the United States. UHS is rolling out the new approach to four pilot sites this year and has plans to launch it in others in the future.

As momentum builds behind Zero Suicide, Goldstein Grumet and her colleagues from EDC are putting support tools. They have recently launched the online Zero Suicide Toolkit, which contains resources, evidence-based programs, and strategies for implementing Zero Suicide in health care settings. They also run monthly conference calls to help health care leaders who are using the approach share successes and obstacles. Finally, drawing on the experiences of health systems that have implemented the approach, a new Action Alliance advisory group is working to clarify the necessary components for a successful Zero Suicide initiative.

Changing attitudes

According to EDC’s Doryn Chervin, the executive secretary of the Action Alliance, the Zero Suicide approach represents a fundamental change in thinking about whether and how suicide can be prevented.

“We want behavioral health and emergency department (ED) providers to take suicide as seriously as they would take a heart attack,” she says. “A doctor wouldn’t allow someone who is having a heart attack to leave the hospital once they are stabilized. Yet this happens all the time for suicidal patients. We want providers to have clear standards of practice for risk assessment and follow up, and we want them to be addressed as they would be for other medical issues.”

But what sounds like a straightforward plan in theory is more complicated in practice. Many behavioral health providers still do not know how to create effective follow-up protocols for patients who may be at risk for suicide. As noted in the Zero Suicide Toolkit, one promising intervention is also one of the simplest: research has shown that even a brief follow-up letter or phone call can reduce the risk of another suicide attempt.

In addition, the issue of suicide still carries significant stigma. This is especially pronounced in smaller communities, where medical staff and patients are more likely to cross paths in everyday life.

“The stigma does prevent assessment and treatment in many communities,” says Chervin. “It’s hard to talk about suicide when the ED nurse is also your child’s soccer coach or someone you see every week at the grocery store.”

Building on success

The Zero Suicide approach is based on some high-profile examples of success in suicide prevention.

In the 1990s, the Air Force implemented a more comprehensive plan to behavioral health, including expanded treatment, counseling, and follow-up protocols for people at risk for suicide. Suicide rates decreased—as did rates of DUI, domestic violence, and substance abuse.

The Henry Ford Health System (HFHS) took a similar approach to suicide prevention in the civilian sector. By using evidence-based treatment methods and placing more emphasis on the identification, assessment, and care for those at risk for suicide, HFHS was able to reduce the rate of suicide among its members by a dramatic 75 percent over four years.

Goldstein Grumet believes these advances are pointing behavioral health care in the right direction—toward a more patient-centered, systemwide approach to preventing suicide. She’s confident that it’s a positive direction for clinicians and their clients.

“Individual clinicians have tried very heroic measures to save individual clients, but there haven’t been systemwide practices and protocols,” she says. “We need to move beyond the ‘we tried our best’ mentality, and realize that there are promising practices that can improve care for those at risk for suicide. We can save lives.”