1. Breaking the Silence

Some behavioral health care professionals are optimistic about a new approach to dealing with rising suicide rates across the U.S., and they place the onus on their own profession.

The new initiative goes by the name Zero Suicide, and the Community Counseling Solutions board of directors adopted the approach at their February meeting.

“In March, I was able to connect with the Zero Suicide institute for consultation,” CCS Executive Director Kimberly Lindsay told the Eagle, noting that CCS will hold its first Zero Suicide leadership meeting in April.

“The process for fully implementing Zero Suicide is lengthy — most say two years,” Lindsay said. “The first year is largely completing organizational and workforce surveys. The second year is using the data to inform changes.”

The problem

Suicide rates in the U.S. have increased steadily from 1999 to 2014 for males and females, according to Centers for Disease Control statistics, with rates increasing slightly since 2006.

In Oregon, the rate increased by 28.2 percent from 1999 to 2016, and suicide has become the eighth leading cause of death in the state. More than six times as many Oregonians die by suicide annually than by homicide.

Men are three times more likely to die by suicide than women, and suicide rates generally increase with age. The highest suicide rate for men is found among those over 85 years old, while the highest rate for women is found between 50 and 54 years old.

But suicide issues also can be found among grade-school aged children. The Oregon Health Authority’s “2018 Oregon Student Wellness Survey” provides self-reported data on a wide range of topics from sixth-, eighth- and 11th-grade students.

According to the survey, the percentage of students statewide who reported experiencing a high level of psychological distress over the past 30 days was 8.9 for sixth-graders, 14.2 for eighth-graders and 16.5 for 11th-graders.

The percentage of students statewide who reported feeling so sad or hopeless almost every day for two weeks or more over the past 12 months that they stopped doing some usual activities was 22.8 for sixth-graders, 29.2 for eighth-graders and 35.6 for 11th-graders.

When asked how many seriously considered attempting suicide, 13.3 percent of sixth-graders answered yes, as did 19.9 percent of eighth-graders and 19.7 percent of 11th-graders. When asked how many actually attempted suicide, the figures were 7.5 percent, 10.2 percent and 8.1 percent, respectively.

Given the high suicide rate in Oregon, DHS Research of Portland sought to measure Oregonians’ experiences with suicide in a recent online survey. The survey found that Oregonians were more likely than the average American to have had suicidal thoughts, know someone who has had suicidal thoughts or know someone who has died by suicide.

In addition, DHS Research found that Oregonians are more likely to feel concern for people they know and are more likely to act on that concern than most Americans. The survey also found that 93 percent of Oregonians would be likely to tell others if they were having suicidal thoughts compared to 73 percent of Americans.

Old approach

Mental health professionals have identified a number of factors associated with suicide, including mental illness and drug abuse, previous suicide attempts, problems with interpersonal or family relationships, recent criminal or noncriminal legal problems, job or financial difficulties, physical health issues, death of a family member or friend, problems at school and exposure to suicidal behavior by a family member or friend.

But according to Lindsay, half of people who die by suicide had seen a general practitioner before their death, and 30 percent saw a mental health professional. In the 60 days before their death, 10 percent were seen in a hospital emergency department.

Victims of suicide “are falling through the cracks in our health care system,” Lindsay said in a Dec. 15, 2018, presentation on Zero Suicide. She is not alone in that opinion.

“Suicide represents a worst case failure in mental health care,” said Michael Hogan, the former State Commissioner of Mental Health for New York. “We must work to make it a ‘never event’ in our programs and systems of care.”

According to the Centers for Disease Control, more than half of people who die by suicide do not have a known mental health condition, which likely means they were not getting the help or support they needed, Lindsay said.

Suicide prevention is a core responsibility for behavioral health care systems, Lindsay said, but many licensed clinicians are not prepared — 39 percent report they don’t have the skills to engage and assist those at risk for suicide, and 44 percent report they don’t have the training.

“Over the decades, individual clinicians have made heroic efforts to save lives,” said Richard McKeon at the Substance Abuse and Mental Health Services Administration, “but systems of care have done very little.”

New approach

“Zero Suicide is a system-wide approach to suicide prevention based on community engagement, in addition to improved systems within the health care system,” CCS Clinical Director Thad Labhart told the Eagle.

The initiative is based on a national model, he said. The Zero Suicide approach is a priority for the National Action Alliance for Suicide Prevention, a goal of the National Strategy for Suicide Prevention and a project for the Suicide Prevention Resource Center.

The Zero Suicide approach is a framework for systematic, clinical suicide prevention in behavioral health and health care systems, a focus on safety and error reduction in health care and a set of best practices and tools for health systems and providers.

The core components of the Zero Suicide approach, according to Lindsay, include commitment to leadership, standardized screening and risk assessment, establishing a suicide care management plan, workforce development and training, implementing effective evidence-based treatment, following up during care transitions and ensuring ongoing quality improvement.

“It is critically important to design for zero even when it may not be theoretically possible,” said Thomas Priselac, president and CEO of the Cedars-Sinai Medical Center in Los Angeles. “It’s about purposefully aiming for a higher level of performance.”

“We will be implementing ZS in all of our counties,” Labhart said about CCS’s new commitment. “While we’ve implemented substantial internal changes in how we identify, monitor and treat high-risk patients, we are really in the infancy phase of ZS from a community perspective.”

Zero Suicide

“Across health and behavioral health care settings, there are many opportunities to identify and provide care to those at risk of suicide,” the Zero Suicide website states. “Before that can happen, suicide prevention must first be seen as a core responsibility of health care.”

Elements of the approach, according to the Zero Suicide website, include leading a system-wide culture change committed to reducing suicides; training a competent, confident and caring workforce; identifying patients with suicide risk through comprehensive screenings; engaging all individuals at risk of suicide by using a suicide care management plan; treating suicidal thoughts and behaviors using evidence-based treatments; transitioning individuals through care with warm hand-offs and supportive contacts; and improving policies and procedures through continuous quality improvement.

The Zero Suicide approach builds on successes reported by the Henry Ford Health System and Centerstone, one of the largest nonprofit community mental health centers in the U.S.

The Henry Ford Health System implemented a system focusing on suicide care using rigorous quality improvement processes and saw a 75 percent reduction in the suicide rate of its health plan members. Centerstone reported a reduction in suicide deaths from 35 per 100,000 to 13 per 100,000 after implementing the Zero Suicide approach for three years.

Health and behavioral health care organizations have found that the Zero Suicide initiative is “feasible without additional funding,” Lindsay said. “It’s working — lives are being saved.”