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Zero Suicide

Posted By Michael Hogan, Tuesday, October 4, 2016

Mike Hogan is the Saturday Plenary Speaker for the 2016 CFHA Conference in Charlotte, NC.  



Increased deaths from suicide are in the news. The Centers for Disease Control recently reported that the increased suicide rate contributed to a rare rise in the overall death rate for Americans in 2015. What can be done to stem this tide? And, while "upstream” prevention efforts are needed, what should health care settings—especially integrated primary care—be doing about suicide?

One would think that detecting and caring for suicidal patients was not new. Unfortunately, this isn’t true. Health and even mental health providers have not been tuned in to suicide care, and the old but receding gap between health and behavioral health care makes things worse. While care for common mental health problems like depression is not adequate in traditional primary care settings, trying to detect and manage suicidality is even tougher.


In multiple studies, up to 45 per cent of all patients and a shocking 78 per cent of older people who die by suicide, saw a medical doctor in the month before they died. But something was missing. In all probability, they were not asked about self-harm or suicide. When it comes to most of health care, a kind of "don’t ask, don’t tell” approach to suicide has been typical.

Suicidal people generally do not want to die but can think of no other way to end their pain. They slip through other cracks in health care as well. In a 2006 study in South Carolina, 10 per cent of all suicide deaths were among people recently seen in emergency departments. They may have been asked about self-harm, if suicidal impulses brought them to the hospital.


But new and effective interventions (such as developing a one page Safety Plan that provides practical alternatives that the patient and family can take, or medical personnel making supportive follow-up phone calls in the days and weeks following the visit) were probably not used.

Another surprising gap is the poor training of most mental health professionals such as therapists, psychologists and psychiatrists in treating suicidal patients. Good training in caring for these patients should be expected, since suicidal patients are usually sent for care to mental health settings. However, these skills are rarely provided in the graduate training of licensed mental health professionals.


A few states, such as Washington and Kentucky, have recognized this gap and passed laws to require continuing education in suicide care. But the gap persists. It means that a referral to specialty mental health care, long thought of as the best way to care for suicidal patients, may not be adequate.


It does not have to be this way. The good news is that effective screening tools and treatments now exist. The bad news is that since these tools are new, they not used yet in most health care settings. We also have evidence that systematic suicide care can be effective. At the Henry Ford Health System in Detroit, the "Perfect Depression Care” effort—a systematic quality improvement program within the behavioral health division—reduced suicide deaths among people receiving care by over 75 per cent.

The new tools for suicide care have been bundled together in an approach we call "Zero Suicide in Health Care,” and implemented successfully in real world clinics and health systems. One of the innovator organizations demonstrating that suicide safe care is feasible in integrated primary care settings is the Institute for Family Health in New York, where suicide care protocols have been successfully embedded in the clinical workflow and EMR. The tools involved in suicide safe care are demonstrated and available at

The approach involves hard work, but it is feasible. Over 200 health care organizations in the United States, with others in the Netherlands and United Kingdom, are now putting it in place. But this is only a beginning. Most health care today cannot be labelled as "suicide safe,” and taking on the mission of suicide prevention is a new challenge for health care organizations. It is especially difficult in health care settings that have not integrated care for mind and body.


The Joint Commission has issued a "Sentinel Event Alert” that puts health care organizations on notice that detecting suicidality among patients should be expected. We hope that these developments, and new leadership among health care professionals to prevent suicide, can make a difference. Suicide is preventable—if we work at it.

Michael Hogan, Ph.D., is a clinical professor in the psychiatry department at Case Western Reserve University School of Medicine in Cleveland.

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