Can we eradicate suicide?
Some health care systems worldwide are trying, through an initiative called Zero Suicide. It treats people attempting suicide as a quality improvement issue, like medication errors or operating on the wrong limb.
This fall it came to Canada through a pilot project at the adult ambulatory care program, which serves more than 1,000 people with complex mental health issues, at St. Joseph’s Hospital in London, Ontario.
Zero Suicide is unique in that it uses the ambitious target to help organizations focus on the issue. Thinking of it as a quality assurance problem encourages tracking of best practices and formally incorporating them into how patients are treated. Most importantly, it encourages organizations to look at suicide in people with mental illness as an independent issue —one that should be screened for and treated separately.
“It’s a way of turning our thinking,” says Dammy Albach, manager of the Community Gatekeeper Training Project for Canadian Mental Health Association B.C. and past president of the Canadian Association for Suicide Prevention. “We are going to behave a lot differently if we believe most suicides are preventable—and there’s a long list of things we can do to prevent them—rather than if we believe suicide is just going to happen anyway.”
The seven-step program is focused on people with mental health problems who are being cared for in health care systems. It’s often run by hospitals, but in some cases, primary care has been included as well. Its recommendations include more screening and making sure patients are linked to other mental-health services after they’ve been discharged from hospital.
Zero Suicide began in the Henry Ford Health System, a non-profit that runs hospitals and health services in Detroit. The “zero deficits” concept—borrowed from the auto industry—was part of a program called Perfect Depression Care. Over 11 years, it reduced suicide rates by an impressive 82 percent, from 97 per 100,000 to 19 per 100,000. Inspired by the early results of Henry Ford’s program and similar initiatives, the U.S.’s 2012 National Strategy for Suicide Prevention brought the key components together into Zero Suicide.
It has since spread to hundreds of health care systems in the U.S., and it’s being tested in the U.K. and Sweden. In Canada, Albach and others across the country who are considering implementing it are watching the pilot project at St. Joseph’s with interest.
Controversy over the concept
The program helped people like Diana Cortez Yanez, who went to a Seattle hospital after her fifth suicide attempt. With major depression and an alcohol addiction, she says she just “wanted to quit suffering.”
Consciously, she very much wanted to die. She even went to the library to research the best way to kill herself. But on another level, she feels that she was fighting to survive. “I could tell because in a couple of my attempts, I did things to help myself survive. It’s almost like when you’re drowning and trying to catch a breath,” she says.
That’s not unusual. In fact, research shows that many people thinking about suicide are ambivalent right up until the moment of their death, says Julie Goldstein Grumet, who oversees the development and dissemination of the Zero Suicide initiative for the U.S.-based Education Development Center.
“There are some studies of people who jumped off the Golden Gate bridge [and survived], and in the five second drop, they changed their minds. In some cases they even tried to position their body so that they could survive.”
But can all suicides really be prevented? Many in the health care field don’t believe so, but say thinking of Zero Suicide as a target is a good idea, even if we’ll never get there.
“It took me awhile to get onboard with the notion of zero suicide, because I objected to its name. ‘Improving the care of suicidal people’ is really what everyone is after, but it’s not as compelling of a title,’” says Barbara Stanley, a professor of medical psychology at Columbia University. “But if you think about zero suicide as an aspirational goal, it puts a different spin on it.”
Stanley also has concerns about the effect it might have on families. “I have heard some pushback from family members who have had a loved one die by suicide, saying it makes them feel that if they had done things right, their loved one wouldn’t have died. So the idea of zero suicide requires some explanation in order to avoid self-blame,” she explains.
Goldstein Grumet counters that she’s seen many families who feel that the system (not a provider) failed their relatives who died, and appreciate efforts to analyze what went wrong after a death.
Bringing Zero Suicide to Canada
Organizations that have tried Zero Suicide initiatives haven’t reduced their suicide rates to nothing. But they have seen success. In addition to the 82 percent drop at Henry Ford, a behavioural health non-profit in Tennessee reduced its suicide rates by 65 percent, from 31 people per 100,000 to 11 per 100,000. A network of community health centres found its rates also dropped.
Those numbers look promising, but will the program work in Canada? That’s what the pilot project in London, Ontario, hopes to answer. Paul Links, the Chief of Psychiatry for both St. Joseph’s and London Health Sciences Centre, is running the program.
He guesses it will cost about $150,000 per year to provide the program in their ambulatory care clinic, with most of the costs going towards additional training for staff. (The money came from hospital fundraising.) He’s expecting to have an initial evaluation done a year from now. If that’s positive, they will roll out Zero Suicide to inpatient units in the hospital as well.
“I thought that Zero Suicide had a lot of potential, and it’s something that deserves to be tried here in Canada,” says Links. “It’s a novel way of tackling the problem.”
1. Leadership that promotes a culture committed to reducing suicide risk.
2. Training for clinicians that is based on staff’s needs and includes a specific focus on suicidal patients (which many post-secondary degrees do not currently provide).
3. Systematic screening for all patients with mental illness, substance use, trauma, loss, family history of suicide, or who have tried to kill themselves in the past. Standardized tools should be used along with clinician’s personal judgement, and are often embedded in electronic health records.
4. Evidence-based suicide care protocols that include offering specialty care and reducing access to ways to kill yourself (such as guns). It also includes clinicians and patients creating a safety plan together, with coping strategies and support people to call (instead of no-harm contracts, which are now shown to be ineffective.)
5. Treating suicidality directly instead of assuming that it will resolve if mental illness is treated. One option for this is dialectical behaviour therapy, an offshoot of cognitive behavioural therapy that includes group skills training, one-on-one treatment, team meetings and coaching over the phone.
6. Providing excellent care during transitions out of hospital, recognizing that many patients never attend follow up appointments after urgent care for suicide attempts and that isolation increases the chances someone will attempt suicide. That includes arranging for outpatient care and having clinicians, crisis call centres or outpatient programs maintaining contact through face-to-face visits, phone calls or even postcards.
7. Conducting quality improvement by tracking measures around process (like how many people are screened) and suicide attempts.
Other ways of treating suicide
In 2009, 3,890 Canadians killed themselves – about 11.5 per 100,000 people. About 60 percent have depression. Men and people 40 to 59 are disproportionately affected, as are indigenous communities, with First Nations communities having rates five to six times higher than the national average. They’re also higher than indigenous suicide rates in New Zealand and Australia.
For Indigenous communities, other issues come into play, including a paucity of mental health resources says Brenda Restoule, a psychologist and chair of the First Peoples Wellness Circle. “If hospitals are linking back to a system that is underfunded and overwhelmed by mental health issues, you’re not likely going to see an overall improvement in suicide rates,” she explains. In contrast, the First Nations Mental Wellness Continuum Framework focuses on a more holistic approach to care, including social determinants of health, land-based programming, and bolstering cultural pride and knowledge.
Zero Suicide also doesn’t help the many people who aren’t in contact with mental health services before they try to kill themselves, says Simon Hatcher, a psychiatrist in Ottawa who works with the Community Suicide Prevention Network. They might be better helped by community-based interventions like The Nuremberg intervention. It includes training family doctors and community facilitators and reduced rates of suicide by about 21 percent in a two-year program.
But for those who are within the hospital system, the program can make all the difference. The first four times Cortez Yanez tried to kill herself, she says, the fact that she was suicidal was never even mentioned. “The psychiatrist wouldn’t even look at me. He’d be looking at my file, saying you’re on certain medication, it must not have been working for you. I felt babysat,” she says. “I felt the same despair the minute I left.”
After her last attempt, Cortez Yanez went into a hospital with a Zero Suicide program. For her, the most important aspects were having a psychiatrist who addressed the topic directly and connected her to a dialectical behavioural program afterwards – he even walked her to her first appointment. “I always had suicide as sort of a back door in my mind,” she says. “I don’t know when I lost that, but sometime in my year of the therapy, it was gone.”
Addendum: Update on the Zero Suicide Initiative (Sept 2018)
The Zero Suicide initiative at St. Joseph’s Health Care in London, Ont., is ongoing. The first phase identified the transition from inpatient to outpatient services to be a particularly vulnerable time for patients, and St. Joseph’s has adapted to ensure all outpatients have a scheduled appointment in ambulatory care within seven days of discharge.
One of the challenges at the outset of the initiative was its title. Many care staff reported heightened feelings of guilt after suicides since adoption of the term. The psychological well-being of health care providers is to be evaluated and addressed in more detail in the second and third phases of the initiative as they begin training in inpatient units and external organizations.