As hospitals and health systems recognize the need to devote more time and attention to population health management and improving community health, more effort correspondingly must be focused on behavioral health services. In response, the American Hospital Association has launched an initiative to assist hospitals with behavioral health.
Of particular importance is the need to provide optimal care for patients at risk for suicide. Unfortunately, myths such as suicide not being preventable continue to impede health care providers from reducing preventable deaths even when evidence-based best practices and protocols for doing so are well known and replicable.
An underappreciated problem
The Centers for Disease Control and Prevention has reported based on 2014 data that nearly three times as many Americans die each year from suicide as from homicide. Moreover, while the homicide rate in the U.S. has fallen 50 percent since the early 1990s, the suicide rate is higher than it was 10 years ago.
Other not-so-well-known facts include:
- Someone in the world dies by suicide every 40 seconds.
- More than half (55 percent) of all American adults have been affected by suicide in some way.
- In the U.S., 11.5 million people have seriously considered suicide; 2.5 million attempt suicide each year.
- One million attempts require medical attention, and 750,000 are hospitalized.
- Over 41,000 Americans are dying by suicide annually.
- Thirty percent of suicide deaths have a relationship to substance abuse.
- About 45 percent of those who die by suicide saw a physician in the 30 days prior to their death, and a quarter of all individuals who died by suicide received mental health care in the year or two before their death.
- HIV/AIDS received $2.9 billion in federal funding in 2013, and the death rate between 2003 and 2013 from AIDS fell 53.2 percent; the equivalent numbers for heart disease are $1.2 billion and 29.1 percent; for prostate cancer, the figures are $266 million and 13.7 percent. Suicide prevention received $37 million in 2013, and the death rate rose by 20.4 percent between 2003 and 2013. Although it is encouraging that President Barack Obama's 2017 budget includes greater funding for suicide prevention efforts, we hope these increases are supported by Congress.
In response to this endemic of suicide deaths, the National Action Alliance for Suicide Prevention was created in 2010. It is the preeminent public-private partnership advancing a national strategy for suicide prevention. In addition to representatives from the U.S. departments of Health and Human Services, Defense, Veterans Affairs, Education and the Interior, the alliance’s executive committee includes members from organizations and companies such as the Joint Commission, Kaiser Permanente, Universal Health Services, the National Football League, Union Pacific, the Kennedy Forum and Facebook.
The National Action Alliance is focused on:
- Championing suicide prevention as a national priority.
- Catalyzing efforts to implement high priority objectives from the national strategy for suicide prevention.
- Cultivating the resources needed to sustain progress.
As one of its most important projects, the alliance, in collaboration with the Office of the Surgeon General, produced the revised 2012 National Strategy for Suicide Prevention, a roadmap for significantly reducing suicide in this country over the next decade. The strategy's goals 8 and 9 promote the health care setting as “one of the most promising environments to implement suicide prevention.” The strategy highlights the need for health care providers and infrastructure to be in place for prevention, accurate identification and effective treatment, including an emphasis on care transition. Goals 8 and 9 were based on the results of leading health care systems that implemented comprehensive suicide prevention efforts and significantly reduced suicide among their patients.
Henry Ford's success
In the late 1990s, the Behavioral Health Services division of the Henry Ford Health System determined that there were 89 suicides per 100,000 members in Henry Ford’s HMO. The national average in the general population was approximately 13 per 100,000. While the rate of suicide in individuals with mental illness is expected to be much higher than in the general population, BHS sought to reduce the number to zero.
According to medical science reporter Tracy Hampton, writing for the American Medical Association, the goal of BHS’ quality improvement initiative (known as Perfect Depression Care) was to "completely redesign depression care delivery using the six Institute of Medicine aims: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Safety improvements strive to avoid injuries patients receive as a result of their care; effectiveness involves providing services based on scientific knowledge while avoiding underuse and overuse; patient-centered care considers individual patient preferences, needs and values and ensures that patient values guide all clinical decisions; timely care reduces delays; efficient care avoids waste; and equitable care does not vary in quality because of personal characteristics.”
C. Edward Coffey, M.D., Henry Ford Health System vice president and CEO of BHS, reported in a 2007 article in The Joint Commission Journal on Quality and Patient Safety that in the initiative's first four-year follow-up interval, the average annual rate of suicide in the BHS patient population dropped 75 percent. Perfect Depression Care served as the inspiration for a National Action Alliance initiative now known as Zero Suicide. Health care leaders interested in adopting this comprehensive approach to suicide care can find information and implementation support at zerosuicide.sprc.org. Aimed at health and behavioral health care systems, Zero Suicide has seven core components:
- Lead: Create a leadership-driven, safety-oriented culture committed to dramatically reducing suicide among people under care. Include suicide attempt and loss survivors in leadership and planning roles.
- Train: Develop a competent, confident and caring workforce.
- Identify: Systematically identify and assess suicide risk among people receiving care.
- Engage: Ensure every person has a suicide care management plan or pathway to care that is both timely and adequate to meet the patient's needs. Include collaborative safety planning and restriction of lethal means.
- Treat: Use effective, evidence-based treatments that directly target suicidal tendencies, thoughts and behaviors.
- Transition: Provide continuous contact and support, especially after acute care.
- Improve Apply a data-driven quality improvement approach to inform system changes that will lead to improved patient outcomes and better care for those at risk.
The results of an 11-year study of Henry Ford Health System’s program were reported in a March 2015 issue of JAMA Psychiatry: “The mean suicide rate for members was 5.77 per 100,000 and did not change over the study period, whereas the annual suicide rate in the general population of the state of Michigan increased significantly (mean, 10.82 per 100,000).”
Health care executives and other health care professionals should emulate the impressive efforts of the Henry Ford Health System, but there are other steps that can be taken:
- Executives should take advantage of the growing number of resources accessible on the National Action Alliance for Suicide Prevention website.
- Primary care physicians and nurse practitioners should be encouraged to use available depression screeners with their patients.
- Health care leaders should carefully consider how to embed the seven components of the Zero Suicide framework in their system of care.
- Health and behavioral health practitioners who identify someone as at risk for suicide should make referrals to competent mental health providers and strongly encourage and support patients to stay in treatment.
- Special attention should focus on reducing stress and burnout experienced by health care professionals. For example, hospital nurses suffer depression at twice the rate of the general population, and the authors of a February 2016 article in the Journal of the American Society of Clinical Oncology stated, “The suicide rate for physicians is higher than that of any other profession — in the past year, more than 400 physicians have committed suicide.”
On Feb. 24, the Joint Commission issued a Sentinel Event Alert on preventing suicide in health care settings. This new alert “aims to assist health care providers, including primary, emergency and behavioral health clinicians, in better identifying and treating individuals with suicide ideation. The alert also provides screening, risk assessment, safety, treatment, discharge and followup care recommendations for at-risk individuals.
A National Action Alliance for Suicide Prevention task force noted, “With suicide being the 10th leading cause — and a preventable form — of death of Americans, its effective prevention and the relief of suffering Americans will not only save lives and untold anguish but also lead to savings and increased productivity by those whose lives we save and help by our actions.” This is a call to action that cannot and must not be ignored.
Paul B. Hofmann, Dr.P.H., FACHE, is president of the Hofmann Healthcare Group, Moraga, Calif., and a board member of the Education Development Center, Waltham, Mass. Jerry Reed, Ph.D., M.S.W., is a vice president of the Education Development Center, for which he directs the Center for the Study and Prevention of Injury, Violence and Suicide in Washington, D.C.