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