Evidence Base

Why these seven elements?

Evidence-based practices were bundled to create the seven elements.

Zero Suicide is based on the best research to date for suicide prevention in health care. Behind each of the seven elements of Zero Suicide are evidence-based practices for safer suicide care. As the research evolves, so will the Zero Suicide framework. Take a deep dive into the research presented below to find out how each element supports best practices. 

 

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System change occurs with sustained and committed leaders who learn and improve practices following adverse events.

Overview: Critical Elements for Effective Leadership

There are several key components to effective leadership for organizations implementing Zero Suicide: (1) utilizing lessons learned from high-reliability organizations, (2) fostering a just culture, (3) maintaining focus on a comprehensive approach to preventing suicide deaths in their systems, and (4) focusing on continuous quality improvement and fidelity to the Zero Suicide model.

High-reliability organizations (HROs), like airlines, rely on leadership to foster a culture of safety. Weick and Sutcliff describe a key element of this culture as “collective mindfulness.”1 ,2  In this type of organizational culture, all levels of workers are attentive to and report errors, failures, and weak signals.1 ,2  Workers in HROs know to be always on alert and are incentivized to speak up about even small issues, creating a responsive culture poised to correct unsafe conditions before safety is compromised.1 ,2  

In these organizations, leadership supports a just culture where experience and patient safety—not rank or title—are at the center of patient care and decision-making. Chassin and Loeb argue that leadership must make a commitment to achieving zero patient harm, promoting a culture of safety, and emphasizing evidence-based approaches1 —all critical elements of Zero Suicide.

Leadership must also maintain a focus on a comprehensive and accountability-centered approach. Findings from organizations implementing a comprehensive approach to reducing rates of suicide and other related measures highlight the importance of this style of leadership.

From 1990 to 2002, the U.S. Air Force implemented a comprehensive suicide prevention program at the community level.3  This program used 11 interventions across 15 functional areas including community-based social service providers, health care delivery, and operational supervision of the occupational community. Interventions included policy changes, senior leadership development, improvements in training, and social network enhancements. This initiative was associated with a 33 percent risk reduction for suicide deaths.3

A comprehensive approach in health care that reduced suicide rates was developed by the Henry Ford Health System (HFHS) and informs the Zero Suicide approach. HFHS’s “Perfect Depression Care” used suicide deaths as the measure of effective depression care in their system. Their goal was “zero defect” mental health care that included 100 percent patient satisfaction and 100 percent accuracy. To achieve this goal, they emphasized a comprehensive approach and strong leadership focus on patient safety and continuous quality improvement. This program reduced the suicide rate among patients receiving behavioral health care from an average of 96 per 100,000 in 1999–2000 to an average of 24 per 100,000 in 2001–2010, a reduction of approximately 75 percent.4

Recommendation: Learn from Organizations Implementing Zero Suicide

The Zero Suicide approach was refined, implemented, and tested over the past several years by behavioral health and integrated primary care programs. These organizations demonstrate that Zero Suicide can be feasibly implemented in ordinary care settings with significant reductions in suicide deaths and other related measures. For example:

At Centerstone, a large, multistate behavioral health nonprofit headquartered in Tennessee, the baseline rate for suicide before Zero Suicide implementation was 31 per 100,000; the suicide rate two years into implementation dropped to 11 per 100,000, a reduction of about 65 percent. 
— Becky Stoll, personal communication, Feb. 22, 2016

Conclusion: Invest in Multifaceted Strategies 

Current research suggests that no single approach will reduce suicide among individuals who are in care. Comprehensive, multi-component, system-wide approaches to suicide prevention have been shown to be effective in broad and diverse settings and likely are the keys to reducing suicide.3 ,4 ,5 ,6  The Zero Suicide approach offers a Toolkit that guides implementers in the process of embedding interconnecting evidence-based practices for suicide prevention into health care systems. One way to assess what components of the comprehensive Zero Suicide approach are currently in place and the degree to which the components are embedded within key clinical areas is to administer the Zero Suicide Organizational Self-Study. It helps to assess organizational and clinical area-specific strengths and opportunities for development across each of the seven elements of Zero Suicide. The Zero Suicide Organizational Self-Study should be retaken on an annual basis as a fidelity check for your organization.

 

Train all staff—clinical and non-clinical—to identify individuals at risk and respond effectively, commensurate with their roles.

Overview: The Need to Train for Safer Suicide Care

It is essential that all staff members have the necessary skills to provide excellent care, which in turn will help staff feel more confident in their ability to identify and to provide caring and effective assistance to patients with suicide risk. Safer suicide care begins the moment a patient initiates contact, and it is critical that all staff understand their role and are trained to provide excellent care appropriate to that role. 

Training is a key component of Zero Suicide because health and behavioral health professionals have regular contact with individuals at risk for suicide. Despite the frequency of these encounters and the significance of suicide risk, studies show that many behavioral health professionals do not receive the training or have the confidence to effectively interact with suicidal individuals.1 ,2  This lack of expertise impacts their ability to provide comprehensive quality care for individuals at risk for suicide.2  

Of all the people who died by suicide, 45 percent of individuals had contact with their primary care provider in the month before death. 77 percent had contact with their primary care provider in the year before death.3  Over 70 percent of older adults who died by suicide had contact with a primary care provider within a month of death.4  In South Carolina, 10 percent of persons who died by suicide were seen in an emergency department in the two months before death.3  Therefore, there are opportunities to screen, identify, intervene, and treat only if 1) health and behavioral health professionals are trained to do so and 2) health and behavioral health systems include this as a part of standard protocols and procedures.  

Recommendation: Comprehensive Training for Suicide-Specific Care

There is evidence that training has an impact on professionals’ confidence, practices, and policies in providing suicide care.1 ,2 ,5  One study assessed whether training in an empirically-based assessment and treatment approach to suicidality administered through a workshop could impact practices, policy, clinician confidence, and beliefs.6  According to Oordt et al., in the 6-month follow-up “results found 44 percent of practitioners reported increased confidence in assessing suicide risk, 54 percent reported increased confidence in managing suicidal patients, 83 percent reported changing suicide care practices, and 66 percent reported changing clinic policy.”5

Health care organizations should assess employees’ beliefs, training, and skills, and provide training appropriate to staff roles. The Zero Suicide Workforce Survey is designed to assess staff self-perception of knowledge, skills, and comfort with patients who are at risk for suicide. This tool can provide an opportunity to assess the competency, culture, and comfort of staff in addition to letting staff know their input throughout the launch and implementation of the system-wide Zero Suicide initiative is desired. As a part of continuous quality improvement and the Improve Element of Zero Suicide, health care organizations should reassess staff with the Workforce Survey throughout Zero Suicide implementation, especially after initiating a training plan.

Conclusion: Safer Suicide Care is Everyone’s Responsibility

According to the Joint Commission, “Clinicians in emergency, primary and behavioral health care settings particularly have a crucial role in detecting suicide ideation and assuring appropriate evaluation.”7  Therefore, an investment in comprehensive training is required.

Training should include: 

  • Screening and identification for all levels of staff that include risk factors, protective factors, warning signs, and early identification 
  • Internal policies and procedures for all levels of staff that outline role-specific training plans and competencies
  • Assessing suicide risk, safety planning, suicide care management plans, continuity of care, referrals, and care transitions for health and behavioral health professionals

 

Screen and assess every new and existing patient for suicidal thoughts and behaviors in an ongoing and systematic way using standardized tools.1

Overview:  Finding Those At Risk

An estimated 12.3 million adults reported having suicidal thoughts in the past year. Approximately 3.5 million people reported making a plan about how they would attempt suicide.2  An estimated 1.7 million reported a lifetime suicide attempt.3  

We know that these individuals at risk for suicidal behaviors are seen in health care settings for a wide variety of concerns. Of people who die by suicide, 77 percent of individuals had contact with their primary care provider in the year before death.4  45 percent of individuals had contact with their primary care provider in the month before death. A meta-analysis concluded that screening lowers suicide rates in adults.5

As the Joint Commission notes in its 2016 alert,1  failure to assess suicide risk was the most common root cause of suicides qualifying as sentinel events. Screening for suicide risk should be included in health and mental health care visits. The known risk factors that should trigger screening for suicide include mental health or substance use diagnoses, psychosocial trauma or conflict, recent loss (e.g., of a job or the death of a family member), family history of suicide, and personal history of suicide attempts.1  

Recommendation: Systematic Screening & Assessment

Evidence-based screening and assessment tools should be incorporated into clinical practice as the use of such tools coupled with clinical judgment have been found to be more accurate than clinician judgment alone.1  Screening can improve identification and treatment of mental health and suicide risk.1 ,6 ,7  Comprehensive screening occurs in multiple settings: primary care, urgent care, specialty clinics, mental health, crisis care, and other settings where individuals at risk are seen. These screenings should occur with every patient, including existing patients, especially when risk factors or life events determine screening is appropriate. Whenever a patient screens positive for suicide risk, a full risk assessment, including risk formulation, should be completed for the patient. 

It is important to develop policies and procedures for screening and assessing patients and to train staff on evidence-based screening, assessment, and documentation tools, policies, and procedures. Simon, et al. examined the relationship between elevated responses to question 9 of the Patient Health Questionnaire-9 (PHQ-9) screening questionnaire and suicide deaths.6  They found a tenfold increase in suicide within the following year for patients reporting frequent thoughts of self-harm, suggesting that routine screening does detect suicidal individuals who should then be engaged for ongoing treatment and care.6

Use of an assessment such as the Columbia-Suicide Severity Rating Scale (C-SSRS) can help reduce the burden on the provider, encourage and streamline follow-up, and improve documentation of risk. The tool can be useful in increasing the quality of information gathered from the patient, encouraging self-disclosure, while also improving care delivery, treatment planning, and outcomes.7  Systematic use of the C-SSRS has been shown to decrease the burden and false positives while improving detection.8  The C-SSRS has been used in the U. S. Marine Corps and the U. S. Army with other suicide prevention strategies and has been associated with a decrease in suicidal ideation and behaviors.9

Further, the research shows that prediction leads to prevention:

“It [the C-SSRS] was able to show, for the first time, that behaviors beyond previous suicide attempts–such as self-injury or making preparations for an attempt–may be used as predictors of subsequent suicide attempts. … It also was able to determine clinically meaningful points at which a person may be at risk for an impending attempt, something that other scales have been unable to consistently determine.”  
— NIMH Science Update, Nov. 28, 2011

In the Zero Suicide model, the Zero Suicide elements are interrelated. It is key to conduct a risk assessment using risk formulation, develop a collaborative safety plan, and use evidence-based treatments in the least restrictive setting.

Conclusion: Take Steps Toward Efficient & Effective Identification

Systematic screening, identification, and assessment of suicide risk among people receiving care dramatically increase the efficiency and effectiveness of interventions. Developing policies and procedures around the identification of risk that leverage evidence-based tools is a crucial step toward safer suicide care.

 

 

  • 1a1b1c1d1eThe Joint Commission. (2016). Sentinel Event Alert, Issue 56: Detecting and treating suicide ideation in all settings. Retrieved from 1. https://www.jointcommission.org/resources/patient-safety-topics/sentine…
  • 2National Center for Injury Prevention and Control. (2015). Suicide: Facts at a Glance. Retrieved from Substance Abuse and Mental Health Services Administration (2022). Key substance use and mental health indicators in the United States: Results from the 2021 National Survey on Drug Use and Health (HHS Publication No. PEP22-07-01-005, NSDUH Series H-57). Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. https://www.samhsa.gov/data/report/2021-nsduh-annual-national-report
  • 3Kessler, R.C., Borges, G., & Walters, E.E. (1999). Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Archives of General Psychiatry, 56, 617–626.
  • 4Abed-Faghri, N., Boisvert, C.M., & Faghri, S. (2010). Understanding the expanding role of primary care physicians (PCPs) to primary psychiatric care physicians (PPCPs): Enhancing the assessment and treatment of psychiatric conditions. Mental Health in Family Medicine, 7(1), 17-25.
  • 5Mann, J.J., Apter, A., Bertolote, J., Beautrais, et al. (2005). Suicide prevention strategies: a systematic review. JAMA, 294(16), 2064-2074. Retrieved from http://www.daveneefoundation.org/wp-content/uploads/Suicide-Prevention-…
  • 6a6b6cSimon, G.E., Rutter, C.M., Peterson, D., Oliver, M., Whiteside, U., Operskalski, B., & Ludman, E.J. (2013). Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death? Psychiatric services, 64(12), 1195-1202. Retrieved fromhttps://pubmed.ncbi.nlm.nih.gov/24036589/
  • 7a7bMundt, J.C., Greist, J.H., Jefferson, J.W., Federico, M., Mann, J.J., & Posner, K. (2013). Prediction of suicidal behavior in clinical research by lifetime suicidal ideation and behavior ascertained by the electronic Columbia-Suicide Severity Rating Scale. The Journal of Clinical Psychiatry, 74(9), 887-893. Retrieved from https://pubmed.ncbi.nlm.nih.gov/24107762/
  • 8Viguera, A. C., Milano, N., Laurel, R., Thompson, N. R., Griffith, S. D., Baldessarini, R. J., & Katzan, I. L. (2015). Comparison of electronic screening for suicidal risk with the Patient Health Questionnaire Item 9 and the Columbia Suicide Severity Rating Scale in an outpatient psychiatric clinic. Psychosomatics, 56(5), 460-469. Retrieved from https://pubmed.ncbi.nlm.nih.gov/26278339/
  • 9Posner, K. (2016). Evidence-based assessment to improve assessment of suicide risk, ideation, and behavior. Journal of the American Academy of Child & Adolescent Psychiatry, 55(10), S95. Retrieved from http://www.jaacap.com/article/S0890-8567(16)30400-2/fulltext

Patients at risk for suicide agree to actively engage in a package of evidence-based practices that directly targets their suicidal thoughts and behaviors.

Overview: Suicide Care Management Plan

When an organization makes a commitment to Zero Suicide, every patient who is identified as being at risk for suicide is closely followed through a suicide care management plan or a pathway to care. It is essential to continuously assess risk, engage patients in their collaborative safety plan, treatment plan, and suicide care management plan and re-engage patients at every encounter, no matter what the reason for the visit. 

All staff members have crucial roles in preventing suicide. A fundamental premise of the Zero Suicide approach is that safer suicide care begins from the moment a patient calls the organization for an appointment, is assessed, or is admitted for treatment, whichever comes first. Suicide risk immediately becomes a primary focus of assessment in a behavioral health or primary care setting if a patient indicates current or past suicidal thoughts or attempts or is identified as at risk through screening.

Evidence shows that outpatient management of suicidal patients can be safe, clinically appropriate, and, at times, preferable to inpatient care.1  Patients at high risk of suicide are often among the highest percentage of those dropping out of treatment.2  The Joint Commission recommends motivational enhancement strategies to increase the likelihood of engagement in further treatment.3  Improvements in treatment compliance for patients at risk for suicide can be obtained through intensive follow-up, case management, contacts, and visits.1  Research shows that improved ease of access to emergency services can reduce subsequent attempts by those who have made their first suicide attempt.1 ,3  

Several studies have shown that engaging patients by beginning interventions and treatment at or as soon as possible after emergency room or inpatient discharge has demonstrated significant reductions in repeat suicide attempts.4  The risk of a suicide attempt or death is highest within the first month after discharge from inpatient or emergency department care.4  Particularly high-risk periods are the first week and the first day after discharge.4 ,5  47 percent of those who died by suicide following discharge died before their first follow-up appointment, and 43 percent of suicides occurred within a month of discharge.5  Up to 70 percent of patients who leave the emergency department after a suicide attempt never attend their first appointment.6  The average performance was only 51 percent on the Healthcare Effectiveness Data & Information Set (HEDIS) measure for one completed outpatient visit within seven days of discharge from inpatient psychiatric hospitalization.6 ,7

Recommendation: Develop a Pathway to Care

Care protocols for patients with high suicide risk are similar to systematic approaches used for other health conditions, such as diabetes or high blood pressure. One protocol for ongoing engagement is a suicide care management plan, also called a pathway to care. Establishing a suicide care management plan involves changes in systems and requires staff buy-in. Implementation policies, outlined in the Zero Suicide Toolkit, include establishing:

  • A screening tool, as outlined in the Identify element of Zero Suicide, and criteria to indicate that a patient should be engaged in a suicide care management plan
  • Same-day access to behavioral health professionals for those determined to be at immediate risk through the use of a standard risk formulation framework
  • Requirements and protocols for safety planning, crisis support planning, and lethal means reduction, including the frequency of visits and actions to be taken if a patient misses appointments or drops out of care
  • Channels for communicating with a patient about diagnosis, treatment expectations, and what it means to have a suicide care management plan
  • A referral process to suicide-specific, evidence-based treatment and requirements for continued contact, especially during transitions in care
  • Criteria and protocols for closing out a patient’s suicide care management plan
  • Training for all staff at least annually in suicide care management plan policies and protocols and documentation requirements so that they understand the reason for these policies and what is expected of them
  • A schedule for regular team meetings and clinical case consultations to discuss patients at risk for suicide
  • A schedule for management to regularly review charts to determine that policies and protocols are followed

Conclusion: Engage and Assess at Every Opportunity

Current research suggests that no single approach will reduce suicide among individuals who are in care. Comprehensive, multi-component, system-wide approaches to suicide prevention have been shown to be effective in broad and diverse settings and likely are the keys to reducing suicide.4 ,5 ,6 ,7  The Zero Suicide approach offers a toolkit that guides implementers in the process of embedding interconnecting evidence-based practices for suicide prevention into health care systems.

Engage: Safety Planning

Safety planning is an essential intervention and component of an effective and evidence-based suicide care management plan.

Overview: Collaborative Safety Planning

Safety planning is an essential intervention with individuals at risk for suicide. It can be done in a variety of settings including emergency departments, primary care, and mental health and is a key component of an effective and evidence-based care management plan. It can be used with individuals who have made a suicide attempt, experience suicidal ideation, or are determined to be at risk for suicide.8 ,9  Safety planning is not be confused with contracts for safety or no-suicide contracts. There is no evidence that these contracts are effective, and they can provide a false sense of security for the provider.8 ,10  Crisis response planning or safety planning have been found to be more effective than a contract for safety.8 ,11

 

Safety planning is a brief intervention involving a prioritized list of coping strategies and supports developed collaboratively between an individual and a clinician. Often, individuals at risk for suicide who are not admitted to treatment by emergency departments or crisis services are referred to outpatient mental health treatment. It is likely that the patient will continue to struggle with suicidal thoughts or emotional crises. The safety plan is an intervention to provide patients with a set of specific, concrete strategies tailored to their individual needs and circumstances that they can use to decrease the risk of suicidal behavior and increase treatment motivation and compliance.12 ,13  Safety plans incorporate elements of several evidence-based suicide risk reduction strategies that are a part of the Zero Suicide approach, including means reduction, brief problem-solving and coping skills, social and emergency crisis support, and motivational enhancement for treatment.12 ,13

Recommendation: Engage a Safety Plan

The elements of a safety plan are as follows:9

  • Warning Signs - Recognition of the signs that immediately precede a suicidal crisis
  • Internal Coping Strategies - Things patients can do to distract themselves without contacting anyone
  • Social Situations That Can Help Distract Me - Places patients can easily access that provide a safe environment (a library, mall, coffee shop, etc.) 
  • People I Can Ask for Help - At least three support persons; persons who are available, able to provide support, aware of resources, and informed that they are a part of the safety plan
  • Professionals or Agencies I Can Contact During a Crisis - Professionals and crisis support agencies including the hours and contact information for current treatment provider, local and regional crisis support, and national crisis support providing 24/7 crisis services
  • Making the Environment Safe - Steps to remove access to lethal means, strategies to limit or eliminate substance use, and any other strategies to maintain a safe environment

Research shows that individuals with higher-quality safety plans are less likely to be hospitalized in the year after safety planning.8 ,14  Interviews with 100 veterans in a qualitative study found that 97 percent were satisfied with their safety plan, 61 percent reported using their plan, and 20 percent reported making changes to their safety plan on their own or with a professional. For those using the safety plan, the aspects that veterans reported were most helpful included social contacts, places for distraction, social support for crisis help, contacting professionals, and internal coping strategies.14 ,15  A recent study found that crisis planning reduced suicide attempts, reduced inpatient hospitalization, and was associated with a faster decline in suicidal ideation in high-risk active duty soldiers.11  

After a comprehensive risk assessment, safety plans are developed collaboratively with the individual at risk for suicide using a problem-solving approach that addresses barriers and explores the likelihood of use. Loved ones and others explicitly mentioned in the safety plan should be educated about their role and responsibilities should the individual come to them for support. 

 

Staff and providers must be trained in creating safety plans, engaging the individual at risk for suicide and any necessary support persons, and documenting and following up on the safety plan. It is important to follow up and conduct internal reviews of staff use of safety planning interventions to determine effectiveness, consistent application, and fidelity of this evidence-based practice, and the need for additional staff training or education.8 ,9 ,12 ,16

Conclusion: Collaborate for Accountable Care

Safety planning emphasizes collaboration between a patient and clinician and operationalizes continuity of care. As one emergency department psychiatrist reported, “I am very satisfied, but partly because [safety planning] helps facilitate my clinical role as an urgent care psychiatrist in that it provides a bridge between the emergency care and outpatient treatment.”15  Research demonstrates that effective safety planning has positive outcomes for patients and patient care management.

 

Engage: Reducing Access to Lethal Means

Reducing access to lethal means is an essential step in safety planning.

Overview: Reducing Access to Lethal Means Works

A key component of Zero Suicide and other effective suicide prevention strategies is reducing access to methods that could be used for suicidal acts and, if possible, restricting access during an acute suicidal crisis. Reducing access to lethal means—particularly those with greater lethality—is essential in safety planning.

Studies around the world have demonstrated that the overall rate of suicide drops when access to commonly-used, highly lethal suicide methods is reduced.17 ,18 ,19  In the late 1950s, the United Kingdom switched from coal gas to natural gas, which is free from carbon monoxide.17  Suicide deaths decreased, saving thousands of lives over the next 10 years. A study in Australia found a decrease in suicide by firearms and in the overall national suicide rate following a 1998 ban on private gun ownership.19

Every safety plan should address reducing access to any lethal means that are available to the patient. Limiting access to medications and chemicals and removing or securing firearms, other weapons, and ligatures are important actions to keep patients safe. This is particularly important in light of findings about the impulsivity of many suicide attempts. Among people who made near-lethal suicide attempts, 24 percent reported taking less than five minutes between the decision to kill themselves and the actual attempt. 70 percent took less than an hour.20  

Based on this evidence, it is clearly possible to increase the chance of surviving an attempt if an individual at risk for suicide has reduced access to lethal means in their moment of crisis. This also has longer-term implications for these individuals. 90 percent of individuals who attempt suicide will not go on to die by suicide at a later time.21  Even with underlying or chronic risk factors, a person’s suicidal crisis is often of short duration and a treating team can significantly help an at-risk individual by limiting access to lethal means.17 ,22  Additional evidence supports that availability of method influences choice of method. If a favored method becomes less available, individuals do not necessarily engage in means substitution.22

Recommendation: Establish Specific Protocols and Effective Policies

Reducing access to possible methods of suicide may be one of the most challenging tasks a clinician faces with an individual at risk for suicide. The Counseling on Access to Lethal Means (CALM) online training is offered free of charge by the Suicide Prevention Resource Center.23  The training is designed to increase knowledge of the association between access to lethal means and suicide and the role of means restriction in prevention. The course is also intended to increase a provider’s skills and confidence to assess and reduce a patient’s access to lethal means.

Research shows that mental health providers demonstrated an increase in knowledge and skills regarding lethal means reduction counseling and sustained change in beliefs and attitudes about the importance of lethal means restriction following a CALM training.23  At a 6-week follow-up from a CALM training, 65 percent of providers reported already counseling on means reduction.24

As a part of the Zero Suicide approach, it is recommended that this training—paired with site-specific policies about reducing access to lethal means—be required of all clinical and, in some cases, non-clinical staff members. 

Specific attention should be paid to protocols about reducing access to firearms. Firearms are the most common method of suicide in the U.S., and more people die by suicide via this method than all other methods combined.17  Every U.S. study that investigated the relationship between firearms and suicide has found that access to firearms is a risk factor for suicide.17  

Organizational policies should clearly state what clinicians are expected to do regarding lethal means. Policies should include the protocol to follow in the event that a patient brings a weapon or other lethal means into a clinical setting. Policies and training should reflect specific steps that clinical and non-clinical staff can take to reduce access to lethal means. These include the process for securing weapons and medications and the conditions under which they may be returned.

Conclusion: Reducing Access to Lethal Means is an Essential Step

It is essential to assist patients through a crisis by actively engaging them to reduce their access to lethal means. Engagement also means developing an individualized collaborative safety plan, encouraging active participation in treatment, and providing patients with a clear roadmap to their care. Using these approaches, clients are more likely to get through their short-term suicidal crisis safely and experience long-term recovery.

 

Utilize evidence-based treatments that focus explicitly on reducing suicide risk to keep patients safe and help them thrive.

Overview: Treating Suicidal Thoughts and Behaviors Directly

Clinicians have historically focused on treating mental health problems, such as depression, substance use, or anxiety with the assumption that a patient’s suicidal thoughts and behaviors would cease once other issues resolved. Recent research strongly supports targeting and treating suicidal ideation and behaviors specifically and directly in the least restrictive environment. These findings were independent of diagnosed mental health or substance abuse issue.1 ,2  The Joint Commission states that care teams should utilize problem-focused clinical interventions targeting skills training and suicidal “drivers.”2  

Several empirically based models of suicide treatment have emerged that effectively reduce suicidal thoughts and attempts, as outlined in the section below. In organizations using the Zero Suicide approach, all staff who treat patients at risk for suicide are trained to use these models of evidence-based treatments regardless of the setting. Additionally, patients should be supported in the least restrictive setting possible.

Recommendation: Use Effective, Evidence-Based Care

Controlled trials demonstrated that Cognitive Behavioral Therapy for Suicidal Prevention (CBT-SP), Dialectical Behavior Therapy (DBT), and Collaborative Assessment and Management of Suicidality (CAMS) are more effective than treatment as usual in reducing suicidal thoughts and behaviors.1

CBT is based on the theory that individuals with issues like depression lack skills for coping effectively with troubling thoughts or feelings. CBT teaches them to recognize these thoughts and provides alternative ways to cope. Studies have demonstrated CBT’s effectiveness with conditions such as depression and anxiety.3 ,4 ,5  Research showed that CBT-SP has resulted in reductions in suicide attempts and symptoms.6 ,7

DBT is an adaptation of CBT developed to help patients with chronic suicidality and other behavior problems. DBT has four components: 1) a skills training group, 2) individual treatment, 3) phone coaching, and 4) consultation team meetings. Studies have demonstrated that DBT is effective in reducing suicidal behavior. Linehan, et al. found that those receiving DBT were significantly less likely to drop out of treatment, attempt suicide, visit psychiatric emergency departments, or be hospitalized. Evidence suggested the skills training component of DBT is particularly significant for patients who are suicidal.8

CAMS is an intensive psychological treatment that is suicide-specific, helping patients develop other means of coping and problem solving to replace or eliminate thoughts of suicide as a coping strategy. CAMS is supported by over 30 years of clinical research, multiple correlation studies, and five published randomized controlled trials.

It has been shown to reduce suicidal ideation and mental health distress when compared to treatment as usual1 and to increase hope as well as reduce self-harm and suicide attempts.2 CAMS has been shown to reduce emergency room3 and primary care visits4 related to mental health and to support ongoing treatment in outpatient settings. Individuals who received CAMS treatment have shown better and sustained reductions in suicidal ideation (at 12 months post-treatment) and increased hope in comparison to those who received treatment as usual.5 CAMS has also been associated with decreased medical health care utilization in the 6 months after the start of suicide-related mental health treatment.3 A study of U.S. Army soldiers showed that CAMS significantly eliminated suicidal ideation in 6-8 sessions significantly more quickly than control care at 3 months follow-up.3 A randomized controlled trial with college students looking at CAMS versus treatment as usual showed that CAMS had a significantly higher decrease of depression and suicidal ideation.6   A recent meta-analysis showed that, in comparison to alternative interventions, CAMS resulted in significantly lower suicidal ideation, general distress, significantly higher treatment acceptability, and significantly higher hope/lower hopelessness. The effect size differences for suicidal ideation were consistent across study types and the age and ethnicity of participants. The effective sizes favoring CAMS were smaller with active duty military/veterans samples and with male participants.7  

Along with an emphasis on treating suicide risk directly with evidence-based interventions, newer models of care suggest that treatment and support of persons with suicide risk should be carried out in the least restrictive setting appropriate for the individual and their risk. Interventions should be designed—and clinicians should be sufficiently trained—to work with the person in outpatient treatment with an array of support and avoid hospitalization if at all possible. A recent article recommended a stepped care pathway in which patients are “offered numerous opportunities to access and engage in effective treatment, including standard in-person options as well as telephonic, interactive video, web-based, and smartphone interventions.”10

Engagement in treatment can increase the efficacy of interventions and can reduce suicide risk.11  Research shows that reaching out to those patients not engaged in treatment through caring letters—communicating support and concern for the patient—may reduce rates of suicide.12  This is particularly true during care transitions or discharge from a more restrictive setting such as inpatient hospitalization. For those patients currently engaging in care, follow-up interventions such as phone calls, postcards, and caring contacts in between scheduled appointments may help to reduce suicide deaths, repeat attempts, and keep a patient engaged in treatment. Participants who received intensive follow-up treatment had fewer repeat suicide attempts than those who received treatment as usual.12

Conclusion: Target Suicidal Ideation & Behaviors

Treatment for those at risk for suicide must target suicidal ideation and behaviors specifically, directly utilizing evidence-based treatments, and should be carried out in the least restrictive setting possible for that patient. Treatment will include a robust suicide care management plan that educates the patients and families about their care. Most behavioral health providers will need additional training in utilizing evidence-based treatments for suicide.

  • 1a1b1cBrown G.K. & Jager-Hyman S. (2014) Evidence-Based Psychotherapies for Suicide Prevention: Future Directions. American Journal of Preventative Medicine,47(3S2): S186-S194.
  • 2a2b2cThe Joint Commission. (2016). Sentinel Event Alert, Issue 56: Detecting and treating suicide ideation in all settings. Retrieved from 2. https://www.jointcommission.org/resources/patient-safety-topics/sentine…
  • 3a3b3c3dGloaguen V., Cottraux J., Cucherat M., & Blackburn I.M. (1998). A meta-analysis of the effects of cognitive therapy in depressed patients. Journal of Affective Disorders, 49(1): 59-72. Retrieved from http://www.sciencedirect.com/science/article/pii/S0165032797001997
  • 4a4bChurchill R., Hunot V., Corney R., Knapp M., McGuire H., Tylee A., et al. (2002). A systematic review of controlled trials of the effectiveness and cost-effectiveness of brief psychological treatments for depression. Health Technol Assess, 5(35): 1-73. Retrieved from http://gala.gre.ac.uk/4982/1/summ535.pdf
  • 5a5bStewart R.E & Chambless D.L. (2009). Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: A meta-analysis of effectiveness studies. J Consult Clin Psychol, 77(4): 595-606. Retrieved from http://psycnet.apa.org/journals/ccp/77/4/595/
  • 6a6bStanley B., Brown G., Brent D., Wells K., Poling K., Curry J., et al. (2009). Cognitive-Behavioral Therapy for Suicide Prevention (CBT-SP): Treatment model, feasibility, and acceptability. J Am Acad Child Adolesc Psychiatry, 48(10): 1005-13. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888910/pdf/nihms148473.pdf
  • 7a7bBrown G., Ten Have T., Henriques G., Xie S., Hollander J., & Beck A. (2005). Cognitive therapy for the prevention of suicide attempts: A randomized controlled trial. JAMA, 294(5):563-70. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=201330
  • 8Linehan M., Comtois K., Murray A., Brown M., Gallop R., Heard H., et al. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry, 63(7): 757-66. Retrieved from http://archpsyc.jamanetwork.com/article.aspx?articleid=209726
  • 10Ahmedani, B.K. & Vannoy, S. (2014). National pathways for suicide prevention and health services research. American Journal of Preventive Medicine, 47(3S2), S222-S228.
  • 11Lizardi, D. & Stanley, B. (2010). Treatment Engagement: A Neglected Aspect in the Psychiatric Care of Suicidal Patients. Psychiatric Services, 61(12). 1183-1191.
  • 12a12bWelu T.C. A follow-up program for suicide attempters: Evaluation of effectiveness. Suicide Life Threat Behav 1977;7(1):17–29.

Put policies into action that ensure safe hand-offs between caregivers and upon discharge.

Overview: Care Transitions are High-Risk Times for Patients

Zero Suicide outlines specific action steps to provide excellent support to transition patients at risk to the next level of treatment. The burden lies on providers, rather than on patients and their family, to develop systems to ensure that patients make and keep appointments.

Caregivers and clinicians must bridge patient transitions from inpatient care, emergency department, or primary care to outpatient behavioral health care. It is equally important to address suicide risk at every visit within an organization, from one behavioral health clinician to another, and between primary care and behavioral health staff in integrated care settings.

Consider these findings from the National Survey of Drug Use and Health during 2008 to 2012.1  Of the adults who reported that they had attempted suicide in the past 12 months:

  • 46 percent received no mental health treatment even though 60 percent of those who attempted suicide had received medical attention for the suicide attempt and 43 percent had stayed overnight in a hospital
  • 60 percent did not participate in any outpatient mental health visit
  • 48 percent of those receiving mental health treatment received only prescription medication for a mental health disorder

This is insufficient care for someone with suicidal thoughts, let alone someone who has attempted suicide. But when organizations use effective clinical bridging strategies they can triple the odds that a patient will link to outpatient care.2  

Research has also demonstrated that some of the highest risk periods are immediately after discharge from an inpatient psychiatric unit and that suicide rates among this group “remain high for many years after discharge.”2

Recommendation: Provide Follow-up & Supportive Contacts 

It is essential to emphasize proactive and personal provider involvement in follow-up care and care transitions.3  The Zero Suicide approach for care transitions stipulates that: 

  • Organizational policies provide guidance for successful care transitions and specify the contacts and support needed throughout the process to manage any care transition
  • Follow-up and supportive contacts for individuals on a suicide care management plan, also called a pathway to care, are tracked and managed using an electronic health record or paper record
  • Patients are engaged in an individualized, culturally sensitive manner that takes into account their needs and preferences
  • Staff are trained how to provide supportive caring contacts and follow-up care using techniques such as motivational interviewing, safety planning, and lethal means assessment and counseling
  • With isolation as a strong risk factor for suicide, successful care transitions are especially important for patients. 
  • Timely supportive contacts (e.g., calls, texts, letters, visits) should be standard at critical times including after acute care visits, once a patient begins treatment, when a patient is in a higher risk period, or when services are interrupted (e.g., a scheduled appointment is missed). Research has demonstrated that caring, handwritten letters sent quarterly to monthly throughout the year for up to 5 years after inpatient hospitalization significantly reduced the number of suicide deaths among patients who received them compared to similar patients who did not.4  This intervention has specifically targeted those who refused long-term care or to engage in the health care system. The effect of the caring letters was significant even in the group who declined or refused treatment.4  Additionally, a recent study found that patients with screening plus intervention, consisting of secondary suicide risk screening, discharge resources, and post-discharge telephone calls focused on reducing suicide risk, showed a 5 percent absolute reduction in suicide attempt risk and a 20 percent relative risk reduction.5

Conclusion: Continuous Innovation for Engaged and Rapid Care Transitions

The emerging standard in suicide care requires innovative approaches to creating smooth and uninterrupted care transitions from one setting to another with support and contact provided throughout by the behavioral health provider, physician, or other designated staff from the organization. Follow-up “caring contacts” with high-risk individuals, such as postcards or letters expressing support, phone calls, and in-person visits, have been shown in randomized control trials to reduce suicide mortality. 6 ,7 ,8 ,9

 

Apply data-driven quality improvement.
Use data to inform system changes that will lead to improved patient outcomes and better care for those at risk.

Overview: A Commitment to Quality Improvement

Organizations that adopt a Zero Suicide approach apply continuous, data-driven quality improvement strategies to ensure improved patient outcomes and better care for those at risk of suicide. Organizations should create a plan to assess system-wide fidelity to a comprehensive suicide care model and to evaluate the outcomes that systems, policy, and patient care changes are designed to produce. 

An organizational commitment to continuous quality improvement is necessary in order to achieve the aim of zero deficits and zero harm. This commitment fosters a culture in which every staff member—no matter their credentials or role—is comfortable with, and even praised for, disclosing errors without deference to authority.1  When defining high-reliability organizations, Chassin and Loeb wrote that these organizations “assess the strength and resilience of their safety systems and the organization’s defenses that prevent errors from propagating and leading to harm.”2  These types of Learning Health Care Systems are only successful in safety-oriented, just cultures where individual providers are supported when a patient attempts or dies by suicide.3

Recommendation: Orient Toward Measurement

Three actions are central to a culture of safety that fully supports high reliability: trust, report, and improve.3 ,4  It is essential to have clear processes for holding employees accountable for adherence to protocols, procedures, and recognizing errors of any size.4

The Henry Ford Health System achieved results through their Perfect Depression Care initiative—one of the inspirations for the Zero Suicide approach—by mapping current care processes, implementing measures of care quality, continually assessing progress, and adjusting the plan as needed. Through data collection and monitoring, Henry Ford Health System and Centerstone, another early adopter of Zero Suicide, found that operational improvements led to clinical improvements:

5  6

The Zero Suicide approach is oriented toward measuring results and improving quality. To assess performance on suicide prevention, organizations should examine both process measures (e.g., screening rates and use of follow-up contacts) and outcomes of care (e.g., number of suicide attempts and deaths among people at risk). However, the category “suicide deaths of people under care” has not yet been adopted as a national health care measure. Due to this, and because official records of suicide deaths may lag significantly, measurement of rates of suicide may be useful primarily as an ultimate measure of safety and quality rather than for performance improvement. 

In creating an evaluation plan for your Zero Suicide initiative, the implementation team should: (1) identify patient care outcomes demonstrating whether systems and policy changes are impacting practice; (2) assess care outcomes for all patients who have a suicide care management plan; (3) develop, review, and improve data collection on suicide attempts and deaths among those in care; and (4) assess the experience and satisfaction of patients who are or have been engaged in a suicide care management plan. It is also important to ensure that you are choosing data that is meaningful for the implementation team and your staff more broadly. To assist in this process, the Zero Suicide Data Elements Worksheet available on the Zero Suicide website provides suggestions for what data elements to measure in an evaluation plan. 

Conclusion: Never Cease to Strive for Perfection

Measuring patient outcomes, maintaining fidelity to the model, and developing a meaningful work plan and evaluation plan are keys to successful Zero Suicide implementation. The Zero Suicide Organizational Self-Study tool is available to assist in tracking progress and fidelity. Administering and re-administering the Zero Suicide Workforce Survey is a good resource for tracking improvements in developing and maintaining a skilled and competent workforce. The prospect of continuous quality improvement can seem daunting, but, to quote surgeon and public health researcher Atul Gawande, “It isn’t reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to strive for it.”7