Why It Matters
In the US every year, over a million people in despair and distress go to an emergency department while contemplating suicide or for injuries due to self-harm. Many undergo a standard intake process and are then left to wait — typically for hours or even days— before receiving or being transferred for mental health treatment.
According to Institute for Healthcare Improvement (IHI) Innovation Team Research Associate Alex Anderson, “Providers are doing the best that they can, but the current approach means people who are in a serious mental health crisis often leave the hospital [before receiving any assistance or appropriate supports].” It is not known how often people in this situation later attempt or complete a suicide, but a better system is clearly needed to prevent these tragic outcomes.
At the request of the American Foundation for Suicide Prevention (AFSP), the IHI Innovation Team began exploring a theory of change and implementation guidance for health care organizations to prevent suicide. For IHI Innovation Team Director Jeff Rakover, one idea came through most distinctly in the research: “Stakeholders across the spectrum in health care have a role to play in preventing suicide.” This idea is supported by evidence indicating that most people who attempt suicide are seen by a health care organization in the year before their death, most frequently in primary care or other outpatient medical settings. Nearly a third of those who complete suicide see primary care physicians or outpatient specialists in the week before their deaths.
Background
Though suicide can affect people from all walks of life, some populations have higher rates of suicide than others. In the US, rates are especially high among older White men and among American Indian and Alaska Native peoples. The age-adjusted rate for veterans is 52 percent higher than non-veterans. Additionally, LGBTQ+ youth are four-times more likely to attempt suicide than non-LGBTQ+ youth and the suicidal behaviors for Black youth increased between 1991 and 2017 while rates of suicide ideation and planning decreased for all other sex, race, and ethnic youth subgroups.
Current research indicates that a range of interventions have the most potential to bring down suicide rates, including reducing access to lethal means, improving depression care and screening, and improving general mental health access and follow-up care. The Innovation Team identified examples including the Zero Suicide approach, the related Perfect Depression Care program at Henry Ford Health, and the UK’s national Suicide Prevention Programme as important exemplars of successful care models.
Reducing Stigma
The Innovation Team also recognized a crucial, but too often ignored, cultural barrier to providing high-quality, patient-centered suicide prevention: the stigma surrounding mental health care and those with mental health needs. Members of an expert panel of people who had survived suicide attempts and family members of those who had completed suicides reported experiencing bias and ambivalence directed at them by providers. Acknowledging the existence of this stigma, coordinating discussions with people with lived experience, and using courses like Understanding Stigma can help. Rakover says, “We have to move on the technical side with screening and brief interventions and lethal means counseling, but on the cultural side, we need to do a better job of making mental health care part of health care to get our suicide rates down.”
Eliminating stigma also has implications for the health of providers. “We know that the pandemic has stressed the health care workforce beyond what we’ve seen before in our lifetimes,” Anderson says, “and the impact on overall mental health and the risk of suicidality among health care workers has reflected that increased burden.” The health care systems, he asserts, should address suicide prevention to both support their own staff and support the population of patients they serve. Rakover adds, “If, on the one hand, you're saying to your health care workforce, ‘we need to provide better suicide prevention care,’ and at the same time, you as a health care leader are not recognizing that we have an extremely distressed health care workforce that has gone through a huge traumatic event for the past three years, that can create cognitive dissonance.”
Anderson reports that the expert panel of survivors and family members highlighted the importance of clear communication in suicide risk screening. “Informing patients that you are going to ask some questions about suicide and then asking, ‘Are you thinking about suicide?’ is more effective than asking something more ambiguous like, ‘How are you feeling?’” he explains. “Clear language can go a long way toward identifying a problem in real time and can itself reduce stigma.”
Anderson also recommends resources like the Substance Abuse and Mental Health Service Administration (SAMHSA) Quick Guide For Clinicians: Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment. Though it was written with behavioral health settings in mind, it offers clear guidance appropriate for any clinical environment. “The language providers use matters,” he says. “Regardless of specialty, all providers can practice being direct when assessing suicide.”
Supporting Non-Specialists
Through interviews with care providers, the Innovation Team learned that many feel unsupported and ill-equipped to help patients experiencing a mental health crisis. According to Anderson, “There is a general lack of familiarity [among non-mental health specialists] regarding what is the best practice when a crisis is happening.” Says Rakover, “You have physicians who, say, ‘Wait a second, this isn't really what I do. This isn't really my role.’”
Research indicates that providing primary care physicians, emergency room physicians, and other non-specialists with reliable referral pathways can help patients connect more quickly with appropriate mental health treatment. For example, as part of their work to spread the Perfect Depression Care approach, leaders at Henry Ford Health assured primary care doctors that behavioral health clinicians would offer same-day appointments for patients identified as in need of suicide prevention care. Institutions like Intermountain Healthcare that use the Zero Suicide approach have embedded behavioral health specialists (e.g., advanced practice nurses) who provide short-term psychotherapy and medication management into primary care settings.
Training health care providers in all settings to have open discussions about gun access is another important and underutilized suicide prevention strategy. In the US, firearms accounted for over 52 percent of all suicide deaths in 2020, and evidence indicates that reduction in access to lethal means — especially firearms — is the intervention with the most potential to reduce suicide.
The BulletPoints 3A’s (Approach, Assess, Act) Framework, for example, guides clinicians through the process of talking with patients about firearm injury prevention. The non-judgmental approach is rooted in cultural humility, emphasizes building rapport, and prioritizes harm reduction and realistic behavior change. A respectful, neutral approach can, for example, include a clinician assuming an at-risk patient has a gun in the home rather than starting by asking about firearms ownership. This approach, Rakover notes, allows the discussion to focus on safe firearms storage or risks in the home (e.g., a family member experiencing suicidal ideation or children in the home).
Not Just a Medical Solution
Evidence indicates that suicide is more than a mental health problem with a medical or psychiatric solution. “We know we have to deal with more than just the clinical delivery of suicide care and suicide prevention care,” Anderson acknowledges. Ultimately, preventing suicide requires focusing on factors that contribute to elevated suicide risk at the population level and addressing an acute shortage of mental health services in the US.
Despite limited resources and continued system pressures in the wake of the COVID-19 pandemic, health care organizations can take important steps to help prevent suicide. While continuing to improve the adoption of screening and brief interventions, health care organizations can prioritize lethal means counseling and improve access to mental health follow-up care. They can also use a variety of training tools available to support physicians, nurses, social workers, and others with a range of suicide prevention efforts.
As Anderson notes, “There are a lot of opportunities to prevent suicide and improve how we help people in the moment, in the right place, and at the right time.”
If you are in a crisis, please call or text 988 or text TALK to 741741.
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