ZERO SUICIDE: DISSEMINATION AND EVIDENCE

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1 ZERO SUICIDE: DISSEMINATION AND EVIDENCE NASEM Suicide Care Workshop Mike Hogan, Ph.D.

2 Zero Suicide at BronxCare: Why now? Inadequate Progress in Suicide Prevention 20% Percent Change in Age-Adjusted Death Rates since 2003 by Cause of Death, % 0% -10% -20% Could we make suicide care more like heart care? -30% -40% Suicide Heart disease Cancer Stroke All-cause

3 Models or Perspectives on Zero Suicide 3 Establishing suicide prevention as a goal and priority in health care...a movement Zero Suicide as a care innovation Quality Improvement priority + Care Bundle, like those for other health conditions

4 4 Action Alliance Clinical Care and Intervention Task Force Report Access at:

5 5 Rapid Evolution in Suicide Prevention Research and Theory since 2000 Suicide prevention in 2000 (NSSP I)--Public Health model, USAF viewed as gold standard but rates keep rising New knowledge: Joiner (Interpersonal Theory of Suicide) Klonsky (Three Stages) Millner et al. (Pathways to Suicide) Suicidal behavior is distinct from (other) mental disorders Vulnerability + Loss - Protective factors Risk Many people have suicidal thoughts, few progress to attempts Developing capability to kill oneself is the dangerous step The time between initial thoughts of suicide and serious attempts is often long this gives us time to help, but only if we know Applying this knowledge to suicide care

6 Suicide and Health Care Settings: A Problem, and Places to Intervene 6 Over 80% of people dying by suicide (>90% with attempts) 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 We have ample time to intervene do we?

7 7WITH IMPROVED SUICIDE CARE, PEOPLE DON T SLIP THROUGH GAPS Ask? Engage, Act for Safety? Reduce Lethal Means? Treat Suicidality? Support when it s needed EDC All rights reserved.

8 Suicide and Health Care Settings: A Problem, and Places to Intervene 8 Over 80% of people dying by suicide (>90% with attempts) had health care visits in the prior 12 months We usually have ample time to intervene Are there effective, evidence-based, feasible tools?

9 Evidence for Suicide Care--Screening 9 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 Defining need for suicide intervention at least as good as for CVD intervention

10 Evidence: Safety Planning plus Follow-Up 10 Stanley et al., JAMA Psychiatry 2018 Safety Planning makes sense, is feasible and has become widely used, but not well tested (Bryan RCT) ED based matched cohort comparison design with 1640 pts with suicide related visit, 1186 in intervention group Tested brief Safety Planning Intervention (SPI) plus telephonic follow up Results SPI+ pts had 45% fewer subsequent suicide behaviors (p<.03) SPI+ pts were twice as likely to participate in follow up care (p<.01)

11 Evidence for Suicide Care: Means Restriction 11 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?

12 Evidence: Caring Contacts 12 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 even better Cognitive Behavioral Therapy also effective

13 Evidence: Directly Treating Suicidality 13 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) As effective as acute care interventions for CVD

14 Evidence: Zero Suicide 14 Usual care is ineffective. Professionals are not trained, patients are not getting what s known to work Effectiveness of innovator sites: Henry Ford, Centerstone, Institute for Family Health Reductions from baseline suicide rates of 60-80% Effectiveness of elements: Culture, QI, Screening, Treatment, Training Early results re: ZS Organizational Assessment (D.Layman, APA 2018) Reliability=.91 Validity: Clinics with higher baseline scores had fewer suicides (p<.05) Much more assessment is needed. NIMH projects (Simon, Ahmedani, Stanley)

15 15 Elements of Zero Suicide Leadership and Support Elements Clinical Elements

16 Tools to do the work: zerosuicide.com 16 Organizational Self Study Workforce Survey Listserv Steaming video courses

17 Are We Making Healthcare Suicide Safe? 17 Early, incomplete progress on orienting healthcare to suicide prevention Joint Commission, NSSP, CARF

18 Joint Commission Sentinel Event Alert 56: Detecting and Treating Suicide Ideation in All Settings 18 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.

19 What ZS Experience Suggests For This Work 19 Intense suicide risk is distinct from (other) mental disorders As with treatment of mental illness, specificity of interventions to the target is essential for effectiveness If an individual has a major mental disorder and is suicidal, treating the mental disorder alone cannot be considered adequate There are now established interventions for suicide care Integrated treatment is likely to be more effective Successful programs using the ZS care model have reduced suicide for populations under care by 60-80% These programs provide a care pathway/protocol for treating/managing suicide risk embedded within the clinic

20 20 Thank You