1. suicide PREVENTION: WHAT's new? What works?
AFSP NE Suicide Prevention Conference 2018
Mike Hogan, Ph.D.

2. Evolution of Suicide Prevention in Healthcare
Suicide prevention in 2000 (NSSP)
Public Health model, USAF viewed as gold standard
“It's not working" (Hogan, 2017)
New knowledge...Action Alliance, NSSP II
New theory, research: Thomas Joiner (Interpersonal theory of Suicide) David Klonsky (Three Stages) Millner et al. (Pathways to Suicide)
What we know, are learning, are doing

3. Health Care Progress Measured by Death Rates
Maybe Another Approach?
Maybe, more like preventing heart attacks?

4. Action Alliance Clinical Care and Intervention Task Force Report--2011
Do people in health care die by suicide?
Are there effective preventive interventions that could work in health care?
Is suicide prevention in healthcare feasible? Effective?
Can advocacy accelerate suicide care?
Access at:

5. Suicide and Health Care Settings
Over 80% of people who died by suicide had health care visits in the prior 12 months
45% of people who died by suicide had a primary care visit in the month before death.
19% of people who died by suicide had contact with mental health services in the month before death.
10% had an emergency department visit in the 60 days
The risk of suicide death following inpatient psychiatric discharge is 44x the population rate
First two bullets:
Third bullet:

6. Suicide in Mental Health Systems
Ohio: Between , 20.2% of people who died from suicide were seen in the public behavioral health system within 2 years of death.
New York: In 2012 there were 226 suicide deaths among consumers of public mental health services, accounting for 13% of all suicide deaths in the state.
Vermont: In 2013, 20.4% of the people who died from suicide had at least one service from state-funded mental health or substance abuse treatment agencies within 1 year of death.
Ohio stat from poster presented at AAS
New York: 226 stat from
13% stat: take 226 divided by 1708 suicides in NY during 2012 (from AAS 2012 fact sheet)

7. EDC ©2016. All rights reserved.
WITHOUT IMPROVED SUICIDE CARE, PEOPLE SLIP THROUGH GAPS
Support when it’s needed
Treat
Suicidality?
Reduce Lethal Means?
Zero Suicide Care Pathway
Engage, Act for Safety?
Ask?
EDC ©2016. All rights reserved.

8. Evidence for Suicide Care--Screening
Simon et al. study (2015):
Examined subsequent history of 75k+ who completed PHQ-9
60% of those who subsequently died by suicide had indicated elevated thoughts on q9
Old thinking: we can’t predict who’ll die, when
Do cardiologists worry about this? We have very good predictors of who needs help

9. Resource: Using the C-SSRS
Access at:

10. Safety Planning Intervention (Stanley & Brown)
Warning signs
Internal distraction
External distraction
Social support
Professional support
Means reduction
Implications, use with youth

11. Evidence: ”Crisis Response Plan” (CRP)
Bryan et al, 2017: RCT of 97 Army soldiers in emergency behav. heath setting
RCT of Soldiers receiving CRP vs. safety contract, at follow-up the CRP showed:
Significantly fewer attempts (75%)
Strengthening patient’s “reasons for living” explained the difference in attempts at follow-up (greater ambivalence)
Significantly faster reduction in SI
Significant reductions in inpatient stay
The Enhanced CRP added Reasons for Living discussion, which
Made clinicians 86% less likely to hospitalize patients, even though risk profile was the same

12. Resource: Safety Planning Intervention
Access at:

13. Evidence for Suicide Care: Means Restriction
Evidence and experience in population level means restriction…it works
Coal gas
Fertilizer
Bridge enclosures
Firearms safe storage
How about we do it for people at risk?

14. Resource: Counseling on Access to Lethal Means
Access at:

15. Evidence: Caring Contacts
Caring contacts (phone calls, letters, texts, postcards, visits) are effective
Schoenbaum et al study (2017)
Caring letters work better than usual care and cost less
Phone calls work better; estimated cost/life saved is 40% of usual economic standard for investing in an intervention ($50k/life year saved)
CBT effective, also costs less than this standard

16. Resource: Structured Follow-up and Monitoring
Access at:

17. Evidence: Directly Treating Suicidality
Evidence for effectiveness of suicide-focused therapies in RCT’s over usual care
Dialectical Behavior Therapy
Cognitive Therapy for Suicide Prevention
Collaborative Assessment and Management of Suicide (CAMS)
(Denmark) post-attempt counseling
(Switzerland) (Attempted Suicide Short Intervention Program—ASSIP)

18. Dialectical Behavior Therapy (DBT)
DBT’s Impact on Suicide Attempt Behavior
DBT’s Impact on Non-Suicidal Self-Injury Behavior
Slide courtesy of David Jobes

19. Systematic Approaches Work
USAF program
While et al. analysis of UK efforts (2009)
Health care

20. Systematic Approaches Work: HFHS
Results replicated at Centerstone (CMH population) and Institute for Family Health (Primary Care): 60-80% reductions from baseline
To date, these are the only systems we know of with systematic approaches, QI, data.
EDC ©2016. All rights reserved.

21. 2012 National Strategy for Suicide Prevention:
A report of the U.S. Surgeon General
and of the National Action Alliance for Suicide Prevention
GOALS AND OBJECTIVES FOR ACTION
GOAL 8: Promote suicide prevention as a core component of health care services.
GOAL 9: Promote and implement effective clinical and professional practices for assessing and treating those at risk for suicidal behaviors.
GOAL 8. Promote suicide prevention as a core component of health care
services.
Objective 8.1: Promote the adoption of “zero suicides” as an aspirational goal by health care and community support systems that provide services and support to defined patient populations.
Objective 8.2: Develop and implement protocols for delivering services for individuals with suicide risk in the most collaborative, responsive, and least restrictive settings.
Objective 8.3: Promote timely access to assessment, intervention, and effective care for individuals with a heightened risk for suicide.
Objective 8.4: Promote continuity of care and the safety and well-being of all patients treated for suicide risk in emergency departments or hospital inpatient units.
Objective 8.5: Encourage health care delivery systems to incorporate suicide prevention and appropriate responses to suicide attempts as indicators of continuous quality improvement efforts.
Objective 8.6: Establish linkages between providers of mental health and substance abuse services and community-based programs, including peer support programs.
Objective 8.7: Coordinate services among suicide prevention and intervention programs, health care systems, and accredited local crisis centers.
Objective 8.8: Develop collaborations between emergency departments and other health care providers to provide alternatives to emergency department care and hospitalization when appropriate, and to promote rapid followup after discharge.
GOAL 9. Promote and implement effective clinical and professional practices for assessing and treating those identified as being at risk for suicidal behaviors.
Objective 9.1: Adopt, disseminate, and implement guidelines for the assessment of suicide risk among persons receiving care in all settings.
Objective 9.2: Develop, disseminate, and implement guidelines for clinical practice and continuity of care for providers who treat persons with suicide risk.
Objective 9.3: Promote the safe disclosure of suicidal thoughts and behaviors by all patients.
Objective 9.4: Adopt and implement guidelines to effectively engage families and concerned others, when appropriate, throughout entire episodes of care for persons with suicide risk.
Objective 9.5: Adopt and implement policies and procedures to assess suicide risk and intervene to promote safety and reduce suicidal behaviors among patients receiving care for mental health and/or substance use disorders.
Objective 9.6: Develop standardized protocols for use within emergency departments based on common clinical presentation to allow for more differentiated responses based on risk profiles and assessed clinical needs.
Objective 9.7: Develop guidelines on the documentation of assessment and treatment of suicide risk and establish a training and technical assistance capacity to assist providers with implementation.

22. Joint Commission Sentinel Event Alert 56: Detecting and Treating Suicide Ideation in All Settings
“The suggested actions in this alert cover suicide ideation detection, as well as the screening, risk assessment, safety, treatment, discharge, and follow-up care of at-risk individuals. Also included are suggested actions for educating all staff about suicide risk, keeping health care environments safe for individuals at risk for suicide, and documenting their care.”

23. Elements of Zero Suicide
So ZS is a framework for providing systematic, clinical suicide prevention and care. I am going to describe this very briefly in the interest of time but encourage you to look at the online ZS toolkit.
The red box really highlights the pieces that need to be in place
a leadership commitment to safety, accountability, and transparency.
And a work force --- beyond just the clinical care team -- that is competent, confident and caring.
The grey box are the components of care
including systematically identifying and assessing for suicide risk, providing care that directly targets and treats suicidality and behavioral health disorders using effective, evidence-based treatments, and contact, engagement and support, especially after acute care.
There also should be a care Pathway -- essentially the protocols and practices that define care management expectations for all persons with suicide risk that is taught to all clinicians and ideally is baked into the electronic health record
We need to have review of data and quality improvement by your implementation leaders regularly.

24. Tools to do the work: zerosuicide.com

25. Are We Making Healthcare Suicide Safe?
Early, incomplete progress on orienting healthcare to suicide prevention
Joint Commission, NSSP
Spread of Zero Suicide:
SAMHSA grant focus
Utah, NYS statewide efforts
Kaiser Permanente
AFSP/Action Alliance “20 by 25” effort
Not yet like heart care, by a long shot

26. Real Change, e.g. 20 by 25—How’re We Doing With Adoption Curve as a Framework?
We are here: Mental Health Settings
We are here: PC, Health Systems, MAT

27. Making Healthcare Safe: New Advocacy Resource
Why? Committed hospitals, health systems will aim for zero
But unless we change ordinary care—in ED’s, primary care etc. people will continue to fall through the cracks
Let’s make suicide care more like heart care
Screen all at risk
Use “suicide care statins”: brief interventions. Resource:
Recommended Standard Care for People with Suicide Risk
Released March 2018 by National Action Alliance for Suicide Prevention
n.org/files/Action%20Alliance%20Recommended%20Standard%20Care%2
Or…Action Alliance web page, search “Recommended Standard Care”

28. Making Healthcare Safe: New Advocacy Resource
Recommends care that should be standard for people with suicide risk in:
Behavioral healthcare (inpatient, outpatient)
Emergency departments
Primary Care
Lists resources to implement the recommendations
“Will you review, and implement changes to keep our loved ones safe?”

29. A Movement and a Mission
“There are those who say that the human body is much more complicated than our airplanes. There are those that counsel patience and say that these patient safety issues are complicated and they simply take time to fix.
But I take a different approach. I wish we were less patient. Every day, when each of us goes to work…we are choosing individually and collectively how many lives are going to be lost…
And the harm is so great, the numbers are so huge, that I don’t think we should wait 20 more years until there are 4 million more preventable medical deaths. We should change the way we do business now. It’s not going to be easy, but it is possible.”
-Chesley “Sully” Sullenberger,
Healthcare Financial Management, 2013