Livestream Event: Suicide Prevention in Health Care Settings

Transcript

STEPHEN O’CONNOR: Hello. Welcome, everyone. Thank you for joining us today. September is National Suicide Prevention Month. And for our discussion today, we're focusing on suicide prevention in healthcare settings. I'm Dr. Stephen O'Connor, chief of the suicide prevention research program at the National Institute of Mental Health or NIMH for short. NIMH has partnered with the Substance Abuse and Mental Health Services Administration to host today's event. I'm joined by Dr. Richard McKeon, a senior advisor for the 988 in behavioral health crisis office at SAMHSA. Richard is part of the team that led the creation of 988, the new and simplified nationwide three-digit voice and text hotline, providing counselors 24/7 for suicide, mental health, and substance use crises. Richard.

RICHARD MCKEON: Thank you. And so let me just mention and we'll be talking more about 988 , which is available to anyone who is having suicidal thoughts or experiencing a behavioral health crisis of any sort. You certainly don't have to be thinking of suicide in order to call and to get help. But today, we won't be making any specific medical or treatment recommendations for anyone or any diagnostic recommendations. But you should be aware there's also a resource in order to find treatment that SAMHSA supports. And it can be found at findtreatment.gov . You see the URL there at the bottom of your screen. So we wanted you to be aware of that. Thanks.

STEPHEN O’CONNOR: Okay. Great. Thank you, Richard. So we'll also use a few minutes of our chat today to answer some of your questions. So please enter them as comments under the live stream on either Facebook or YouTube. And we'll do our best to answer as many of those as we can in the time that we have. I'd also like to introduce Dr. Brian Ahmedani, who's the director of the center for health policy and health services research at Henry Ford Health. We're going to hear from Brian just a little bit about some of the really great work that he's been leading. So suicide is a major cause of death in the United States, and many people at risk don't get the mental healthcare that they need. In many cases, people see a healthcare provider in the weeks or months before they make suicide attempts. And that makes settings like emergency departments or doctor's offices key points for prevention and intervention. So NIMH and SAMHSA provide funding for research and programming that's aimed at enhancing suicide prevention efforts, particularly within healthcare settings. This work focuses on improving identification, intervention, and treatment strategies to reduce suicide risk among individuals receiving healthcare services. So NIMH and SAMHSA have supported Dr. Ahmedani's efforts in these areas over the years. So we're really glad to have him join the discussion today. One of the ways that NIMH and SAMHSA have supported work to advance suicide prevention in healthcare settings is through a learning healthcare approach that's known as zero suicide. So Brian, would you describe how it originated, what's involved, and the types of projects that you've been working on?

BRIAN AHMEDANI: Yes, thanks so much, Stephen. Overall, the goal of zero suicide is that instead of thinking that suicide is inevitable like we used to, we're now thinking that suicide is preventable and that healthcare systems have a responsibility to try and prevent every single suicide possible. The zero suicide approach focuses on improving practices within healthcare settings to better identify and support individuals at risk for suicide. Our goal with the zero-suicide model at Henry Ford is to achieve zero suicides among those who receive healthcare in our system and then go even further to partner with others to eliminate suicide throughout our communities. So the key areas of the framework, zero suicide, are screening and assessment. Here, we emphasize the importance of routine screening for suicide risk and behavioral health in primary care and in many other medical settings like the emergency department. We advocate for the use of standard and universal tools to identify individuals who might be at risk even if they are not presenting with obvious mental health or suicide risk issues. With universal screening tools, it really helps clinicians discern when patients might be at risk. The next step is really engagement and treatment. When someone discloses having suicidal thoughts, we engage them into creating a safety plan to help manage suicide intensity and stay safe. We also emphasize the use of empirically supported treatments for suicide prevention like cognitive behavioral therapy for suicide prevention and dialectical behavior therapy. We leveraged supportive care coordination, improved access, 988 crisis lines like Richard was already referencing, and other local resources to provide comprehensive services aimed at delivery of care, where and when the patient needs it.

BRIAN AHMEDANI: So the next step is follow-up and continuity of care. This approach also highlights the need for effective follow-up procedures for individuals at risk for suicide. This includes ensuring patients receive ongoing support after the initial assessment and intervention. Transitions in care can be really difficult, especially when people have more acute settings and return home. So it's important to stay connected and provide support while they establish and return to care with their outpatient team of providers. Also, training and education, really important. Training of healthcare providers to recognize and address suicide risk is really important. This includes enhancing their ability to communicate with patients about suicidal thoughts and providing appropriate referrals and support. And finally, one of my favorite topics, data and outcomes. I often use data and driven approaches to evaluate the effectiveness of suicide prevention strategies in our healthcare systems. And our research team includes analyzing outcomes related to the implementation of screening programs and interventions. So those are the most common areas of zero suicide. Overall, we've got a lot of data that show that this model works, not only at Henry Ford but at many other different kinds of healthcare systems. The zero-suicide model originally was developed in 2001 at Henry Ford Health and has showed immediate progress. The system, our health system, Henry Ford, measures suicide rates within one year of a patient visit, and we began experiencing up to 70 to 80 percent reductions in our suicide deaths in the years that followed implementation.

BRIAN AHMEDANI: In our recent NIMH-funded research study, we also found that implementing the zero-suicide model across six different healthcare systems across the country, serving more than 10 million patients per year, was associated with significant reductions in suicide attempts and deaths in behavioral health clinics. Importantly, and also as part of this study, Dr. Julie Richards at Kaiser Permanente in Washington also led a systematic implementation of our zero-suicide model in 22 different primary care clinics. The implementation was linked with up to a 25% reduction in suicide attempts in that setting. These encouraging data have now supported larger-scale efforts and approaches, such as our My Mind program, which is a partnership between provider organizations and Blue Cross Blue Shield to implement the zero-suicide model in all of the primary care and behavioral health settings across Michigan. In addition, through support from SAMHSA, we have also developed innovative zero-suicide models stemming from the emergency department. We are also further studying ways to link community organizations and partners with healthcare settings to reach individuals at risk in those areas as well. This includes our state-funded refugee pilot program and our NIMH-funded suicide prevention center called NCHATS, which is studying ways to link the criminal legal setting with our healthcare systems for cross-sector suicide prevention, consistent with one of the primary goals of our recently released national strategy on suicide prevention. As the new leader of Zero Suicide International, our team at Henry Ford is partnering with leaders from over 20 countries around the world to work on strategies to prevent suicide globally.

STEPHEN O’CONNOR: Wow. Very busy making a huge impact in doing really rigorous science in order to inform what the most effective ways to implement this are. And so we can't thank you enough for the work that you do and making a huge impact and really starting to see partnerships all around the globe. So really exciting to see that. And I'm glad that you brought up the center that you co-lead. And I would just mention to people that that was an effort by NIMH to accelerate research that can really have a near-term impact on reducing suicide risk in the country. So those are called practice-based suicide prevention research centers. And the aim there is to use clinical practice settings as real-world laboratories where multidisciplinary research teams can work together, they can develop, they can test, and they can refine their approaches, and they can figure out in partnership with these practice partners what can actually be implemented and scaled up and sustained over time. And they're really focusing on groups that have traditionally had disproportionately high risks of suicide, or maybe in more recent years, there's been a disproportionate increase in their risk over time that really places them at an elevated level compared to other groups. And so in line with NIMH's commitment to addressing mental health disparities, those centers are really kind of focused on those groups and wanting to understand what's going to work best for those communities of practice, what really resonates with the people who are receiving the services because we really want that to fit. We don't want to just try and plug and play things, and then they're not going to be acceptable or sustainable. So we're talking about health services. And certainly, those learning healthcare approaches are important.

STEPHEN O’CONNOR: Richard was also talking about SAMHSA's lead role in developing 988 and really, I think, changing the vision of the role that crisis services play as part of the network of healthcare. So we really wanted to spend some time talking about that expansion as well. So Richard, could you talk a little bit more-- a little bit more about 988 and how the Lifeline came about? SAMHSA is the lead agency in operating and developing this. So really interested to hear about that from you.

RICHARD MCKEON: Sure. Thank you, Stephen. I'm glad to be able to talk to people today about 988. And it's a fascinating story in terms of how it came about. The United States has had a national hotline network focused on suicide prevention and mental health crises for a significant period of time, and it's called the National Suicide Prevention Lifeline. It was launched in 2005. Both SAMHSA and NIMH did evaluation and research studies that demonstrated its effectiveness. But the way to access it was through a 10-digit number, which was at the time, 1-800-273-8255. But the issue was that a 10-digit number is a difficult thing to remember in the middle of a suicidal crisis, right, by contrast. And SAMHSA in our report to the Federal Communications Commission, first recommending a three-digit number, made the point that if somebody was experiencing severe chest pains and was with a family member, it's likely both the person and the family member is going to remember the number 911. But in a suicidal crisis, it was unlikely that either the person or the family member was going to remember 1-800-273-8255. So our feeling was that a three-digit number would be easier to remember and would lead more people to be able to access when they were in crisis and that that would help us save lives.

RICHARD MCKEON: So 988 was launched in July of '22. And in the little over two years since that launch, we have responded to over 10 million people who contacted us by phone, by chat, or by text. And 988 is also available by text as well as by calling. Both of those were by order of the Federal Communications Commission. And so we are very pleased that we have been able to accomplish this, but we have additional goals as well, Stephen.

STEPHEN O’CONNOR: Yeah. Tell me a little bit more about that. Thank you. I understand there are these three broad horizons with the vrisis services network in 988. Could you kind of speak to those a little bit and what the timeframe is for those?

RICHARD MCKEON: Yes. We were hoping when 988 was launched that a three-digit number could play a transformative role in behavioral health crisis services in much the same way that over a half a century 911 became a catalyst for the development of emergency medical services in the United States. And the way that we framed our goals has been in to have someone to talk to, and that's what 988 provides 24 hours a day, 7 days a week, 365 days a year. But also, someone who can respond, such as a mobile crisis team that can respond to where the person is, and that can go without the police, unless there's a specific reason that an ambulance or police would be necessary such as a suicide attempt in progress. And a safe place to go for help. And one of the things that we wanted to accomplish was to reduce the burden on emergency departments. We know too many emergency departments across the country have experienced significant emergency room boarding. And so that people may be in an emergency department but not able to get the help that they need. So crisis stabilization units outside of hospitals and similar programs can be safe places for help. So that is kind of the three-part stool. Not that there aren't other very important services. But those are the three key services that SAMHSA identified in our national guidelines for behavioral health crisis services.

STEPHEN O’CONNOR: Okay, great. Thanks. And you mentioned the impact that you've been seeing in terms of the uptake and increasing and reaching people in response. Are there any innovations that have come about with the crisis line or any of the other work that you were mentioning?

RICHARD MCKEON: Yes. Absolutely. And both the chat and the tech services are relatively recent innovations. And Dr. Madelyn Gould from Columbia has published on the effectiveness of the Lifeline chat service. And she's also published on text outcome data from the crisis text line. And one of the things that we know is that young people are more likely to text than to call, and they are also more likely to have current suicidal ideation. So those are really important. But there are other additions that we've made. For a long time, we have had a connection to the veterans' crisis line , a press one option, as well as a Spanish-language subnetwork when you can press two. But we have added, since July '22, several additions. While we had a Spanish language subnetwork for phone, there is now Spanish language chat and text. There is also now a national press three option for LGBTQI+ youth as well as chat and text that go along with that. We have added a video phone for those who are deaf and hard of hearing and who need that to facilitate their access. And in the state of Washington, they've even added a press four option to allow connection to a program called Native and Strong, a hotline affiliated with one of our centers where the entire staff is American Indian and are able to provide those kinds of culturally specific and competent services.

STEPHEN O’CONNOR: Yeah. Okay. It's just really impressive about trying to deliver the best option that's going to be the best fit for different groups of people to make sure that we can really help them be as effective as possible. So I love hearing about that. If someone is watching today and they're saying, "Okay, I don't work in one of these crisis centers. I'm not a trained provider," what would I do if someone I knew loved was having suicide experiences? What could I do that would be helpful, protective for them? Do you have any recommendations that you'd cheer?

RICHARD MCKEON: Yeah. So I would mention a couple of things, if you're worried about someone, first off, don't be afraid to ask the question, "Are you thinking about suicide?" It's not an easy question in the sense people are often anxious because they don't know what to do if the answer should be yes. But sometimes people are very isolated with their suicidal thoughts and won't bring it up themselves but may very well acknowledge that they're thinking about suicide if asked. And then being aware that 988 exists. Letting people know that it's there for them. And if somebody's unsure about a situation, 988 can be called by family members or friends if you're worried about someone else. You're not sure how to handle a situation, 988 is there. But one of the things that's really important regarding to ask the question is that one of the most important things someone can do is really to be there with the person, right, so that they are not isolated with their suicidal thoughts, that someone doesn't panic when they hear that but to express the caring and concern. And it's useful to have information about what kind of help is available. 988 is one, but of course, also accessing mental health services, talking to your primary care provider is there. Now, another important piece to be aware of is the importance of keeping people safe, particularly during the interim if they're having suicidal thoughts. And that means that paying attention to the issue of whether the person has access to lethal means, right?

RICHARD MCKEON: In the United States, about 54% of suicides are by firearms. And so safe storage of firearms is an important suicide prevention measure. But there are also maybe other things to pay attention to in terms of medications. We also have looked at the importance of various kinds of barriers to jumping. For a long time, people are familiar with the story of the Golden Gate Bridge, where they're now finally working on building a barrier there. So anything that can reduce access to lethal means, even sometimes for a short period of time, can be instrumental in saving a life. And then following up with a person. We would all wish that if you got through a terrible moment or the worst day of your life, that everything would be fine. But sometimes suicidal thoughts might recur. And so following up with people staying connected and helping to connect the person to care. We used to think on the hotlines that it was like a one-and-done intervention. Now we really promote follow-up after the call, staying in contact until the person is connected to a health or mental health provider.

STEPHEN O’CONNOR: Okay. Well, thank you. So one of the take-home messages there is that you don't have to be perfect. It is good to know in advance, just some really fundamental things that you can do that could help that person in that moment. You don't have to fix all the problems. But I think being calm, kind of knowing what your plan is, there are things that you can do that can help instill some hope and help convey to that person that they're not alone, and you're going to be with them as they kind of go through that dark moment, and it's something that you want to do. You're choosing to do that. So thanks for describing that. I think the last thing I wanted to touch upon with you I was hoping that you would be able to talk about was ways that healthcare providers can take care of themselves as well. Thinking about people who are working in the crisis call centers, thinking about first responders. Do you have any tips for people about how they can attend to their own mental health as they're helping other people?

RICHARD MCKEON: I think that's a really important point, Stephen. It's very important for healthcare providers, behavioral healthcare providers, and crisis workers, whether it's on the lines, on mobile teams, to be aware of the impact on their own mental health of what they experience. And repeated exposure to people who are thinking about suicide, but also people who have made a suicide attempt and, of course, death by suicide, has a powerful impact. And it's very important that people are aware of that impact and get the support they need, which can be through supervision. It can be peer supervision or with your direct supervisor. It's very important for crisis services to have a defined approach to supporting the wellness of the people working with them. So on the Lifeline on 988, there is support that is provided through our administrator, Vibrant, to call centers when there has been exposure, particularly to a death by suicide. And this is really important.

RICHARD MCKEON: We know, for example, that if you look at one type of first responder police officers, police officers have a really significant exposure, repeated exposure to deaths by suicide. But also, other healthcare providers and behavioral healthcare providers have heightened exposure. And we know that we need to pay attention to their behavioral health because repeated exposure to suicide can increase one's own suicide risk. So it's really important to pay attention to it and for organizations that provide crisis services or behavioral health or healthcare in general to provide to the needs of their workforce.

STEPHEN O’CONNOR: Okay. Yeah. Thank you. We've got some really great questions here. So we only have so much time. Brian, I'd love to hear your take on this. It's about training the workforce. And in real-world health settings, emergency departments, specialty clinics, what approaches do you take to ensure that the healthcare providers are competent, they're skilled, they're ready to help the people that come in with suicide intensity?

BRIAN AHMEDANI: Yeah, it's so important. What a good question. This is tough. It's not easy to do because we're all so busy with making sure we see patients and a healthcare system is really busy. But you have to prioritize it to make sure people are delivering effective care. So one strategy is to make sure everybody has training when they come in through orientation. Another thing I really highly recommend is that we really choose consistent approaches that are really pragmatic. And that's why really simple screening tools, really simple brief interventions, and really structured protocols so people know exactly what they're supposed to do when they're supposed to do it. It can be really effective and easy brief ways to train your staff in your healthcare system. But we have to be creative. All of our healthcare providers also have to get continuing education credits so we can leverage that to try and make sure we can offer solutions that are both effective care options but also meet the demands of continuing education for our providers. And we can use creative strategies to arrange trainings on times that work best for our healthcare systems and delivery of care so we can make sure to get patients the care that they need when they need it.

STEPHEN O’CONNOR: Okay. I mean, this is a huge focus, Richard, for SAMHSA too is ensuring that there's a workforce that is ready to deliver equitable suicide prevention care. Any thoughts that you have to say about that as well?

RICHARD MCKEON: Just that I agree entirely, right? And one of the things that we've been focusing on is that there is a workforce for crisis services and that people are aware early in their career that it can be a career trajectory for folks. Most of us who have spent many years in crisis services didn't start off planning that as a career. So we're really working on trying to help develop the pipeline for that, as well as to improve training in healthcare professions for suicide prevention more generally and for behavioral. It's been part of several of the U.S. national strategies, including the most recent one released this past April. The importance of training in suicide prevention. I often tell the story that when I was in my training, I was only exposed to one lecture on suicide. The irony was the one lecture that I was exposed to was the one that I gave because our teacher said, "Pick a topic and present to the class," and I picked suicide. But literally, that was the only class on suicide that I got during my graduate training or during my internship, even though in both, I was seeing suicidal people. And of course, we talked about it in supervision, but it's a really important area to enhance training.

STEPHEN O’CONNOR: Yeah. Okay. And I think we're out of time here. I'm sorry. We're going to answer more of the questions later on. But I would say that NIMH shares the prioritization of training. We had a workshop a couple of years ago that was completely devoted to training the clinical care workforce in suicide prevention best practices. And we also have active notices of funding opportunity announcement to help support research to build up the foundation of science in crisis care services. Things are moving really quickly, but there's still this really great opportunity to conduct rigorous research that's going to inform clinical practice in the future. You can reach out to me if you have an interest in learning more about that notice of funding opportunity announcement or any other research that you're interested in conducting that NIMH might be able to fund. So we've reached the end of our discussion today, and I really appreciate you spending time with us, submitting thoughtful questions. Again, if you know someone or if you were in crisis, please call or text the 988 Suicide & Crisis Lifeline  at 988. You can visit 988lifeline.org  for help and information. And I appreciate Richard and Brian for joining us, sharing their expertise. And I look forward to seeing you all again in the future. So thank you all very much.

RICHARD MCKEON: Thank you, Stephen.

BRIAN AHMEDANI: Thank you.