Zero Suicide: Transforming Healthcare, Eliminating Suicide
C. Edward Coffey, a professor of Psychiatry and Behavioral Sciences at the Medical University of South Carolina, begins his presentation with a statement that is both a troubling snapshot and a call to action: “We have a real crisis in this country with regard to suicides.”
Coffey’s presentation, “Vision Zero: Eliminating Suicide & Transforming Healthcare,” the kickoff session of the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30, noted that suicide rates in the United States increased 35 percent from 1999 to 2019.
Coffey cited the landmark “Crossing the Quality Chasm: A New Health System for the 21st Century,” a damning report by the Institute of Medicine two decades ago, for helping lay the foundation for Zero Suicide, a model aimed at preventing suicides among patients in healthcare systems.
“Our thought leaders are saying back in 2001 that our system is broken,” Coffey said. “And, furthermore, it is so badly broken that we’re not going to fix it by tweaking at the margins. We need to basically tear it up and start over. Remember, this criticism is not coming from a fringe group, but was authored by the thought leaders in international healthcare.”
Part 1 in a series about the Zero Suicide Model for Healthcare
Coffey pointed to 2021 research published by the Commonwealth Fund showing how the United States ranked “dead last” among well-developed high-income nations in overall healthcare, access to care, administrative efficiency, equity, and outcomes. The same research, he noted, found that the U.S. ranks dramatically lower than the other nations in value for money spent on healthcare. “Although the Chasm report was written 20 years ago and it bemoaned our healthcare system then, the unfortunate news is that problems persist,” he said.
The Chasm report described six dimensions of ideal healthcare, Coffey explained; “healthcare should be safe, effective, patient-centered, timely, efficient, and equitable.”
He took up the challenge himself by becoming a leader in developing what has become known as the Zero Suicide Model, designed to prevent suicide deaths through systemic quality improvements within healthcare systems. In the early 2000s, Coffey led the Perfect Depression Care Initiative at Michigan’s Henry Ford Health System. The initiative achieved an 80 percent reduction in suicide deaths among Henry Ford patients including a decline to zero suicides in some annual reporting periods.
With a grant from the Robert Wood Johnson Foundation, the initiative sought to apply perfection goals for suicide prevention to the Chasm report’s elements of ideal healthcare. It began by applying the audacious goal of eliminating suicides to the element of effective care. Other goals included eliminating medication errors and achieving 100 percent patient satisfaction in the areas of patient-centered care, timely care, efficient care, and equitable care.
Coffey stressed that improving suicide care requires creating a “just culture” in the healthcare workplace, a “culture in which mistakes and errors are viewed as system issues, not personal failings, [and] are viewed as opportunities for learning and for improving the system, not punishing people. It’s profoundly important. We can’t ask our teammates to go up to plate and try to hit a home run every time, and then turn right around and punish them for striking out.”
Zero Suicide protocols that grew from the Henry Ford experiment include leadership of a system-wide culture change committed to reducing suicides, training a competent workforce, identifying individuals at risk with comprehensive screening and assessment, engaging at-risk individuals with care management plans, treating suicidal thoughts and behaviors with evidence-based treatments, and transitioning patients through care with warm hand-offs and supportive contacts.
Coffey said that early adopters of the Zero Suicide Model are now replicating Henry Ford’s advances. Among them: Centerstone, which provides mental health and addiction services in Tennessee and other states; Gold Coast Mental Health and Specialist Services, in Australia; and 110 community mental health clinics in New York State.
Coffey noted how Zero Suicide’s standards and goals are embedded in U.S. health policy and accreditation guidelines and requirements, such as the 2012 National Strategy for Suicide Prevention and The Joint Commission’s National Patient Safety Goal for Suicide Prevention (NPSG) 15.01.01.
Addressing colleagues who bemoan the immense challenges of preventing suicide deaths, Coffey recalled the internal discussions in developing the Perfect Depression Care Initiative at Henry Ford.
“What number of suicides are we going to tolerate? Is 12 suicides a year the right number? Is that numbering your parent or my sister? We realized that the only answer to this question is zero. Our goal has to be zero. And at that moment, our department was transformed. We stopped trying to be the best, we stopped trying to improve incrementally, and we began to strive for perfection in all of our goals. What does it mean to be the best in a mediocre industry? ‘Being the best isn’t good enough. We’ve got to pursue perfection.”
Coffey emphasized the importance of leadership in implementing the Zero Suicide Model. “Leadership involvement is essential to the success of this kind of work,” he said. “This cannot be the flavor of the month. It can’t be the quality improvement project of the month. It has to be a system-wide initiative.”
Zero Suicide: Safe Care in all Healthcare Settings
Michael Hogan, former New York State Commissioner of Mental Health and co-developer of the Zero Suicide Model, asks healthcare professionals to reconsider conventional wisdom.
How much should we rely on upstream suicide prevention efforts like reducing suicide causes and risk factors such as trauma, mental illness, addiction, economic insecurity, pain, loss, and isolation?
Speaking at the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30, Hogan agreed that upstream strategies are important and worthy of pursuit.
Yet, he warned in his presentation, “If Preventing Suicide is our Target, Suicide Safe Care—in all Healthcare Settings—Is the Bullseye,” upstream strategies are nonetheless “woefully inadequate and unlikely to affect rates of death in the next several decades.”
“It’s unreasonable to expect rates of suicide to decrease because of upstream prevention activities unless we really, really dramatically increase them,” Hogan explained. “We have inadequate access to care, as a very significant number of people with mental health problems don’t get care. The great majority of people with addiction problems don’t have access to care. Reducing suicide by curing depression is a very tough call. Big factors like economic insecurity or human pain and loss and isolation are very tough things to fix in our society.”
Part 2 in a series about the Zero Suicide Model for Healthcare
Hogan noted that the success in preventing cardiovascular disease by reducing smoking through upstream activities included 30 surgeon general reports, national and state education campaigns, anti-smoking laws, and significant taxes on tobacco products—and still required a 50-year effort that remains unfinished.
Hogan argued that the suicide prevention field can learn from other medical fields that have achieved decreasing rates of death, from heart disease and cancer, for example, due to preventive interventions. He likened the potential of utilizing the Zero Suicide Model for those at risk of suicide to the success of preventive interventions and treatments such as statins, stents, and valve replacements for those at risk with cardiovascular disease.
As heart disease deaths have been reduced through targeted preventive interventions for people at elevated risk, Hogan said, suicide risk can be mitigated by identifying and managing suicidality through targeted preventive interventions such as screening, safety planning, reduction of lethal means, and caring contacts.
“Just as we can identify high blood pressure through a blood pressure screening, or high cholesterol through an examination of blood chemistry, we can identify those who are at risk of suicide,” Hogan said. “Then, even more importantly, there are things that we can do that are effective. We’ve now got evidence that very brief, small interventions are quite effective in reducing rates of suicide.”
Hogan pointed to research demonstrating the effectiveness of patient screening for identifying suicidality, and of safety planning protocols for reducing suicide behaviors. He cited a 2013 study that looked at more than 75,000 patients who completed the PHQ-9 Patient Health Questionnaire, which found that 80 percent of the respondents who subsequently died by suicide had indicated elevated suicidal thoughts in the survey.
Another study Hogan cited showed a 45 percent reduction of suicide behaviors among patients who received safety planning. Still another study showed a 50 percent reduction in suicide deaths among patients receiving follow-up caring contacts from healthcare providers; caring contacts are phone calls, text messages, letters, or postcards, which are deemed to decrease isolation and increase connectedness.
For treatment of suicidal individuals, Hogan said, just as heart disease can be treated through interventional cardiology, suicidality can be treated with Cognitive Therapy for Suicidal Patients (CT-SP) and Dialectical Behavior Therapy (CBT).
Healthcare settings are ideal places for addressing suicide, Hogan said, because more than 80 percent of people dying by suicide and more than 90 percent of people attempting suicide had healthcare visits, and 40 percent had received emergency department care, in the prior 12 months; in the month before death, nearly half of those who died by suicide had a primary care visit, and nearly one-fifth had contact with mental health services.
“If we want to save lives from suicide, broader encouragement and action that focuses on suicide safe care especially in mainstream healthcare settings and most especially incapable or integrated primary care is our best bet,” said Hogan. “I would advocate that that would be the single most feasible effective action we could take to reduce rates of suicide.”
Pressing for suicide care in primary care practices, Hogan added, “It’s almost as if when it comes to suicide we don’t do anything except hope that people see a specialist. I’m going to make the argument that we now have tools for suicide care in primary care that are effective, comparable to things that we now do to care for the heart. So the argument is, let’s care for the brain the way we care for the heart.”
Hogan argued for a culture change in healthcare thinking about behavioral health treatment. “It’s an easily understandable but sad paradox from my point of view that care for the heart is very well established as a primary care responsibility—we know what the internist is supposed to do and what the cardiologist is supposed to do, and the lines of referral between the two are pretty clear—but the care for the brain isn’t that well established.”
Hogan noted emerging evidence that Zero Suicide has reduced suicide rates where it has been adopted compared to usual care. For example, he said the Henry Ford Health System in Michigan achieved a 75 percent reduction; Centerstone in Tennessee a 65 percent reduction; and the Institute for Family Health in New York a 65 percent reduction.
Zero Suicide: A National Perspective
Richard McKeon, Branch Chief for Suicide Prevention at the Substance Abuse and Mental Health Services Administration (SAMHSA), highlights that Goal 8 of the 2012 National Strategy for Suicide Prevention encourages healthcare programs to “explicitly adopt the goal of Zero Suicide.”
Goal 8, McKeon noted in “A National Perspective on Zero Suicide in Healthcare,” a presentation to the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30, was reiterated in the U.S. surgeon general’s “Call to Action” issued in January 2021.
“The public and private sector looked at where we were in terms of suicide prevention and came to the conclusion that it wasn’t that we needed a new strategy but rather we needed to be vigilant about implementing the strategy that we have and the things that we know work and bringing them to scale,” McKeon said. “One of those things was Zero Suicide.”
McKeon reviewed the core components of Zero Suicide:
- Makes suicide prevention a core responsibility of healthcare
- Is a systematic approach in health systems, not the “heroic efforts of crisis staff and individual clinicians”
- Applies new knowledge and proven tools for suicide care
- Supports efforts to humanize crisis and acute care
- Is embedded in The Joint Commission Sentinel Event Alert and the 2012 National Strategy for Suicide Prevention
McKeon also outlined Zero Suicide’s “pathway to care” model:
- Create a leadership-driven, safety-oriented culture
- Develop a competent, confident, and caring workforce
- Identify and assess risk, by screening and assessing
- Provide evidence-based care, including a safety plan, restricting lethal means, and treating suicidality directly with proven therapies
- Provide continuity of care
“There needs to be agreed upon guidelines for care, such as those that Zero Suicide provides, around identifying and assessing suicide risk, what the approach is for screening, and then for those who are identified as being at risk for suicide an approach to assessment, and that they have access to evidence-based care,” McKeon explained.
Part 3 in a series about the Zero Suicide Model for Healthcare
McKeon pointed to the use of recent assessment and treatment tools, such as the PHQ-9 Patient Health Questionnaire, C-SSRS Baseline Screening, and the Brown Stanley Safety Plan; and to several therapies for treating suicidality directly: Dialectical Behavior Therapy (DBT), Cognitive Behavioral Therapy (CBT), Collaborative Assessment and Management of Suicidality (CAMS), and the Attempted Suicide Short Intervention Program (ASSIP).
He highlighted restricting access to lethal means as a key evidence-based protocol of care that should be systematically adopted. He also noted that Zero Suicide protocols steer clinicians away from harmful practices.
“For years, clinicians were relying on what was called ‘no suicide’ contracts because we weren’t providing them with anything better to utilize in working with people who were at high risk,” he said. “We know that ‘no suicide’ contracts were not only not effective, but there was also some evidence that they were counterproductive because patients in some sense accurately perceived they were more about the clinician or the system’s desire for protection from liability than it was about them and their pain. And of course, it wasn’t effective to protect against liability, either.”
Another practice that Zero Suicide warns against, McKeon said, is directing healthcare clients to fill out a Patient Health Questionnaire that omits the question about suicidal thoughts and self-harm. “Dropping the suicide question is like putting on the medical chart, ‘If this patient is suicidal, we don’t want to know,’” he said.
Research supports the value of providing continuous contact and care for suicidal individuals, McKeon said. For example, he said that a survey of healthcare clients’ perceptions of care published by Columbia University researchers showed that 58.9 percent felt that follow-up phone calls helped “a lot” in stopping themselves from taking their own lives, and 21 percent said the calls helped “a little.”
“Ubiquitous and inexpensive technology is changing nearly every other industry,” McKeon said. “At a time when we can track a package halfway around the world, it should be unacceptable in the United States of America for us to lose track of people at high risk for suicide within the lethal gaps in many of our systems.”
McKeon said he understood why the idea of Zero Suicide has been controversial, with skeptics saying “we’re never going to be able to get there.” He said he empathized with a feeling among family members as well as clinicians who have lost loved ones or patients that Zero Suicide suggests that they should have been able to prevent the deaths. “That’s not at all what we mean, we sometimes talk about the preventability of suicide in too quick a way,” he said.
McKeon argued that Zero Suicide is an important goal representing “an assault on the fatalism around suicide that has held us back for many years, including in mental health components… What we mean is that no suicide is fated, no suicide is predestined, no matter how high the risk, until the person takes that final fatal step. There is always hope that they can be averted from that trajectory.”
A core belief of Zero Suicide is that the mission cannot be left to the efforts of an individual clinician but rather requires the dedication of the entire healthcare system, he stressed.
“When we say [suicide prevention] is a core responsibility of healthcare, it is really important that that’s not misinterpreted as the responsibility of individual clinicians,” McKeon said.
“For too long, but it is now changing with Zero Suicide, suicide prevention depended on the heroic efforts of individual clinicians or crisis staff, and many tried heroically to save lives and did save lives. But they were not backed up by a systematic approach within their system. It’s that systematic approach that really works.
“There’s a protocol for care for people who have been identified at higher risk, and there is consensus about how to assess the risk and about the treatments that can effective. That’s what Zero Suicide is about.”
McKeon outlined various other recent steps the federal government has taken to advance suicide prevention. He cited provisions in the 21st Century Cures Act of 2016 that authorized the National Suicide Prevention Lifeline into law for the first time and reauthorized the Garrett Lee Smith Memorial Act that provides grants for youth suicide prevention.
He outlined some of the progress being made in implementing Zero Suicide across the United States. He said SAMHSA has provided 35 Zero Suicide grants, and that implementation is underway in the Indian Health Service and the Air Force.
Zero Suicide: Implementing the Model in Health Systems
Brian Ahmedani, director of the Center for Health Policy and Health Services Research at the Henry Ford Health System, argues that a two-decade surge in the United States suicide rate underlines the need for greater efforts to prevent deaths by suicide.
“The suicide rate is the only cause of death right now in the U.S. that over the last 20 years has actually been increasing,” said Ahmedani in his presentation, “Implementing Zero Suicide in Health Systems,” at the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30.
“All of the other leading causes of death in the U.S. have annual rates that are either relatively stable or have actually been dropping pretty substantially over this period,” he said.
Ahmedani made the case for preventing suicide in healthcare by pointing to his own landmark research published in 2014 based on data from nearly 6,000 suicide deaths that more than 80 percent had seen a healthcare provider in the previous 12 months, almost 50 percent within a month, and more than 20 percent within a week.
Moreover, he said, the greatest number of individuals who died by suicide were not receiving mental health services, and more than half did not have a mental health diagnosis, pointing to the importance of using other healthcare settings such as primary care practices to identify suicidal individuals.
“We really need to think about how we can put high-intensity services in the settings where the fewest people go but who are at the highest risk, and then make sure that we also have low-intensity services in those settings where there are lots of people going to get care and most people are not at risk but where most people are touching before they die by suicide,” he said.
Part 4 in a series about the Zero Suicide Model for Healthcare
Ahmedani credited the 2012 National Suicide Prevention Strategy for the landmark mandate determining that suicide prevention is a core responsibility of healthcare. He said that the Zero Suicide Model, developed at Henry Ford, took that mandate forward and provides the tools for a “golden era” of preventing suicide in healthcare.
At Henry Ford, he said, “We really focused on providing better care overall for our patients, and after doing that we saw a pretty substantial 75 to 80 percent reduction in suicide deaths over time in our health system. We were able to sustain that for almost 20 years now. You can think about all the numbers of lives that have been saved just because of that kind of care.”
He credited the development of many tools throughout the last 20 years, such as the PHQ-9 Patient Health Questionnaire, C-SSRS Baseline Screening, Brown Stanley Safety Plan, Dialectical Behavior Therapy (DBT), and Collaborative Assessment and Management of Suicidality (CAMS).
“This field is in its infancy stages, but yet we have all of the tools now,” Ahmedani said. “So we are in the opportunity phase of being able to implement those things into practice, and to use not only the knowledge that’s available from, and the structure that we developed at, Henry Ford, but also piggyback on all the research that’s been done across this entire time.”
“We also need the leadership and the bold vision to push these things forward,” he added.
Ahmedani shared that Henry Ford is participating in three initiatives to further advance the Zero Suicide Model.
He said that Henry Ford and Kaiser Permanente are currently involved in a five-year study in six healthcare systems in Michigan, Washington State, Colorado, Oregon, and California covering 10 million patients a year to evaluate the implementation of the Zero Suicide Model. The study is examining the health system metrics for driving implementation, fidelity to those metrics, and whether faithful implementation reduced suicide deaths.
A second initiative is a five-year comprehensive program to “revolutionize” suicide care within the Henry Ford Health System’s emergency departments, he said. It entails universal screening of every ED patient, risk assessments and safety plan counseling for positive screens, bridging referrals to behavioral health care through telehealth appointments with therapists, and post-discharge caring contacts.
Finally, Ahmedani said that through an initiative called MI-MIND, Zero Suicide processes are going to be implemented over the next few years in the five largest healthcare provider organizations across the state of Michigan in coordination with Henry Ford.
“We’re facilitating a suicide learning collaborative with healthcare systems that includes a monthly or a quarterly call to talk through their local implementation challenges, barriers, and opportunities, and work together as systems across the state,” he said.
“This is a model for going from one system, doing the core implementation in behavioral health that spread to primary care, the emergency department, the hospitals, and all of our systems internally, to then spreading to new and revolutionized opportunities across multiple systems across the state,” he said.
“We have done this in Michigan, we have done this in different places across the state, and each of you has the opportunity to use this as a model to work across New York. Let’s let Michigan, let’s let New York, be leaders in the nation in suicide prevention.”
Ahmedani said that the Zero Suicide has been adopted by the national health systems or local health systems in more than 20 countries. “This thing is growing like wildfire,” he said.
Zero Suicide: Best Practices for Primary Care
Virna Little, Chief Operating Officer & Co-Founder of Concert Health, a national organization providing behavioral health services to primary care providers, trumpets the importance of preventing suicide in primary care.
Research shows that about 84 percent of people who die by suicide, and 92 percent of those who attempt suicide, had a healthcare visit within a year of their acts, Little said in her presentation, “Best Practices for Primary Care,” at the Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30.
Little also cited recent research indicating that people who died by suicide had suddenly resurfaced in primary care and became active on their healthcare portals within a month of their deaths.
Little spoke of her experience in conducting Zero Suicide trainings for 3,000 primary care providers in 27 states. She found that while 95 percent of the providers considered suicide prevention as part of their role, many of them were not trained either in their current positions or in their previous education. She found that many felt they did not have the knowledge or time to assess and intervene with an individual at risk of suicide.
She added that more than half of the behavioral health providers in these primary care settings did not feel comfortable or confident to care for someone at risk for suicide. She found that some people in her trainings were not familiar with the standard Patient Health Questionnaire that includes a key screening question about self-harm (PHQ-9).
Part 5 in a series about the Zero Suicide Model for Healthcare
Little reported that many providers who had received traditional suicide prevention training did not feel it was helpful due to the trainers’ lack of understanding of how primary care practices operate.
“There are all kinds of places in primary care where people can fall through the cracks,” she said. “What I wanted to do was bring the idea of Zero Suicide and suicide safer care right to the front line, to make sure that we were doing something that would change what was happening in the primary care visit for people that were at risk for suicide.”
In her experience engaging primary care providers, Little said, they could easily identify their population of patients who suffered from diabetes but were usually silent when asked about how many of their patients were at risk for suicide.
Little felt that pediatric providers don’t really understand the extent of the problem of youth suicide. She cited data from the 2019 Youth Risk Behavior Survey conducted by the Centers for Disease Control and Prevention indicating that 8.9 percent of high school students in the survey had attempted suicide in the past year, and 18.8 percent had seriously considered taking their own lives.
In her training, Little urges primary care providers to adopt the seven core elements of the Zero Suicide Model, to bring a systemic approach to suicide care into their practices. Little stressed the importance of engaging everyone in a primary care practice, whether physicians and nurses or front desk and billing staff, in the process of suicide care.
“I often give an example of a practice where somebody canceled three appointments within a very close time frame and died by suicide,” Little said. “Nobody who answered the phone knew that she was at risk for suicide to do anything different. There was no process in place to catch that.”
Little’s training takes providers through the Zero Suicide protocols: effective screening procedures, speaking directly with patients identified as at risk, safety plans for patients, referrals to behavioral health specialists, and follow-up caring contacts.
She advises primary care providers to include suicidality on their patient problem lists, which provide immediately accessible structured data on their patients’ most important illnesses, diseases, injuries, or other health issues. “Imagine telling your primary care provider something really important, and then the next time you came in nobody even remembered,” she said.
Little said she also speaks with primary care providers about creating “pathways” of care for suicidal patients within their practice and thinking about appropriate levels of care so that suicidal patients are not automatically dispatched to hospital emergency departments.
“For example, everybody that comes in with chest pains, we would probably do an EKG, not everybody would go to the emergency room,” she said. “Not everybody who is asthmatic goes to the emergency room. So, one of our jobs in primary care is to make sure that people get the appropriate level of care.”
Little said that she found suicide care became more relatable when the primary care providers understood how discussing a patient’s suicidal thoughts with them and making referrals was a little different than the usual workflows they use for patients with other issues like high blood pressure or asthma.
“Making those comparisons for primary care providers was incredibly helpful because it really helped them say, ‘Wait a minute you know what? I actually do this.’ I would remind them that, yeah, we shift gears all day long in primary care. It would be a beautiful day in primary care if somebody came in and they just had one thing going on and it was the actual thing that was the most urgent. If you’re going to engage primary care providers in this work, you have to speak primary care.”
She also said it was useful to provide primary care practices with role modeling for visits by individuals at risk for suicide and to share storage statements with them that can be used to speak with such patients. She takes primary care providers through a role-play of getting an at-risk individual to put the National Suicide Prevention Lifeline number in their phone contacts, or to access www.nowmattersnow.org, a website that shares stories of how people have coped with and survived painful emotions.
Zero Suicide: Opening Pandora’s Box in Emergency Departments
Edwin Boudreaux, professor of Emergency Medicine, Psychiatry, and Quantitative Health Sciences at the University of Massachusetts Medical School, advocates for universal suicide risk screening for patients entering a hospital emergency department.
The emergency department (ED), he said in “Zero Suicide Work in Emergency Departments: Opening Pandora’s Box,” his presentation to Suicide Prevention Center of New York’s “AIM for Zero: Suicide Care is Healthcare” symposium September 28-30, presents an opportunity to identify and provide support for individuals at risk for taking their own lives.
He cited research indicating that some 40 percent of people who died by suicide had made an ED visit within the year, and mostly for reasons other than a personal mental health crisis. “A substantial proportion of them are being seen for a psychiatric crisis, but many of them aren’t and then they’re dying by suicide in the weeks or months after that visit,” he explained. “Is there something better we could do to try to detect that suicide risk prior to the person dying?”
Boudreaux also cited research showing that when ED patients were systematically screened, a larger than expected percentage indicated an elevated suicide risk due to recent suicidal ideation or a past suicide attempt.
Part 6 in a series about the Zero Suicide Model for Healthcare
Bourdreaux himself led a universal screening study covering eight EDs across the United States. That study found that the use of universal screening was feasible to implement and that it detected suicide risk in 5.7 percent of patients compared to 2.9 percent in “treatment as usual” settings.
“The emergency department is a suicide risk environment, but we’re missing most of the patients who have suicide risk by using our existing approaches of just screening patients who are presenting with frank psychiatric symptoms,” Boudreaux said. “We demonstrated that it was feasible to do the [universal] screening and that when we did this improved screening we actually improved detection.”
Boudreaux called universal screening a “Pandora’s Box” because of a common fear among healthcare administrators that such screening could challenge workloads and “break” the ED system. He said they worry about the lack of behavioral health providers, at-risk patient observers, boarding capacity, training for handling suicidal patients, and the time required for making assessments. In addition, he said, administrators are concerned about creating patient dissatisfaction among individuals seeking ED services for non-mental health conditions.
“The biggest fear people have is, ‘What if I ask the question about suicide and they say yes. Then what do I do?’” he said. “The objection is it’s simply not feasible. There’s no way you can implement universal screening because it’s going to break the emergency department.”
For making the screening itself more feasible, Boudreaux pointed to Computerized Adaptive Tests, or CATS, a research-tested technological innovation in screening, and a CATS tool for youth known as the Computerized Adaptive Screen for Adolescents, or CASSY. He noted that traditional mono-dimensional quick-screen instruments like the C-SSRS Baseline Screening focus only on suicidal ideation and behavior. He said that CATS conducts screens quickly and with improved fidelity and efficiency, and also addresses multiple dimensions (such as depression, PTSD, suicidal ideation/behavior, and trauma history) yielding a spectrum analysis with more precise results and allowing a more complex risk formulation.
Boudreaux acknowledged the challenges of implementing universal screening in hectic EDs. He said that his study found that sometimes clinicians go through the motions of screening and mark a patient negative for suicidal thoughts without actually asking them the question.
Boudreaux argued that opening Pandora’s Box is doable if EDs use their Clinical Decision Rules with the support of the CATS tool, and follow the Zero Suicide Model of efficient and appropriate pathways for suicide care.
“You have to establish a very clear protocol,” he said. “People can’t be confused or vague about what they do when they ask the screener and if they get a yes, or if they get a mild, moderate, or high risk. There can be no ambiguity. Your institution has to have very clear policies and procedures around the stratification of those patients and what happens. You can’t treat all risks the same. It’s a huge resource burden.”
He said, for example, many patients screening positive for suicidal ideation do not need full psychiatric examinations or intensive safety precautions such as observation or boarding. He said that patients screening for mild risk could be given a referral to a behavioral health provider and educational materials to review.
Boudreaux highlighted the imperative that EDs understand the need for compassionate and evidence-based intervention that takes into account the patient’s values and preferences.
“They want respect,” he said. “Their idea of safety is treating is them with compassion. They want to feel like they can trust the clinicians who are working with them and not overreact if they share that they’re suicidal and get the security guard involved and have to strip search them and admit them to an inpatient unit. It’s going to make them feel vulnerable. It’s going to make them feel traumatized, not safe.”
Zero Suicide: Crisis Care for Everyone, Everywhere, Every Time
David W. Covington, a member of the Executive Committee of National Action Alliance for Suicide Prevention, begins a call for upgrading mental health crisis response systems in America with an analogy to a 2010 accident at a gold and copper mine near Copiapó, Chile/